MEDICARE: SOUTH LAKE FAMILY DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	7981	WA

General Provider Information

NPI Number	:	1275942518
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH LAKE FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	10515 20TH ST SE
Second Line	:	SUITE 201
City	:	LAKE STEVENS
State	:	WA
Zip	:	98258-4764
Country	:	US
Telephone Number	:	425-334-9600
Fax Number	:	425-334-9900

Provider Business Practice Location Address
First Line	:	10515 20TH ST SE
Second Line	:	SUITE 201
City	:	LAKE STEVENS
State	:	WA
Zip	:	98258-4764
Country	:	US
Telephone Number	:	425-334-9600
Fax Number	:	425-334-9900

Authorized Official
Title or Position	:	OWNER
Name	:	DR. TODD MIESEL
Credential	:	DDS
Telephone Number	:	425-334-9600

Provider Enumeration Date	:	08/12/2014
Last Update Date	:	08/12/2014

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