MEDICARE: DR. KELLY RAE IRWIN DMD

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	600757252	WA
2	122300000X	Dentist	DE60757252	WA

General Provider Information

NPI Number	:	1598295354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY RAE IRWIN DMD

Provider Business Mailing Address
First Line	:	14650 N KELSEY ST STE 104-105
Second Line	:
City	:	MONROE
State	:	WA
Zip	:	98272-1456
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	14650 N KELSEY ST STE 104-105
Second Line	:
City	:	MONROE
State	:	WA
Zip	:	98272-1456
Country	:	US
Telephone Number	:	360-694-8580
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2017
Last Update Date	:	06/14/2017

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