1194828566 NPI number — NORTHSHORE ENDODONTICS PLLC

Table of content: (NPI 1194828566)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194828566 NPI number — NORTHSHORE ENDODONTICS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHSHORE ENDODONTICS PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194828566
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5701 NE BOTHELL WAY
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
KENMORE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-488-9785
Provider Business Mailing Address Fax Number:
425-402-0835

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5701 NE BOTHELL WAY
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
KENMORE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-488-9785
Provider Business Practice Location Address Fax Number:
425-402-0835
Provider Enumeration Date:
09/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SAMYN
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MANAGER OF NE PLLC
Authorized Official Telephone Number:
425-488-9785

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  DE00006931 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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