Healthcare Provider Details

I. General information

NPI: 1760977854
Provider Name (Legal Business Name): NICHOLAS JON FORSYTHE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2018
Last Update Date: 06/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16825 SMOKEY POINT BLVD
ARLINGTON WA
98223-8407
US

IV. Provider business mailing address

11302 4TH AVE NE
TULALIP WA
98271-9446
US

V. Phone/Fax

Practice location:
  • Phone: 360-653-5197
  • Fax:
Mailing address:
  • Phone: 425-870-8546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE60850654
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: