1124048947 NPI number — MR. GARY JAMES MAGUIRE MSPT

Table of content: ERIC CHAREST DDS (NPI 1750739801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124048947 NPI number — MR. GARY JAMES MAGUIRE MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAGUIRE
Provider First Name:
GARY
Provider Middle Name:
JAMES
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSPT
Provider Gender Code:
M

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:
1124048947
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4220 132ND ST SE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
MILL CREEK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98012-8999
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-357-9380
Provider Business Practice Location Address Fax Number:
425-357-9382
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT00005702 , 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: 0305497 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0052459 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0305498 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0305474 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0305483 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8339913 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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