1255832663 NPI number — DAVID GAGE DMD PLLC

Table of content: (NPI 1255832663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255832663 NPI number — DAVID GAGE DMD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID GAGE DMD 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:
DAVID GAGE DMD
Provider Other Organization Name Type Code:
4
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:
1255832663
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 W FAIRHAVEN AVE STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98233-1062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-757-0651
Provider Business Mailing Address Fax Number:
360-757-3741

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 W FAIRHAVEN AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98233-1062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-757-0651
Provider Business Practice Location Address Fax Number:
360-757-3741
Provider Enumeration Date:
02/22/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GAGE
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
ALEXANDER
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
360-757-0651

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  DE60472401 , 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)

  • Identifier: 1952719957 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1952719957 . This is a "NPI" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".