Healthcare Provider Details

I. General information

NPI: 1942533351
Provider Name (Legal Business Name): KENT NUTTALL DMD PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2009
Last Update Date: 09/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 12TH ST SE
AUBURN WA
98002-6708
US

IV. Provider business mailing address

722 12TH ST SE
AUBURN WA
98002-6708
US

V. Phone/Fax

Practice location:
  • Phone: 253-939-0700
  • Fax:
Mailing address:
  • Phone: 253-939-0700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7439
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number10882
License Number StateWA

VIII. Authorized Official

Name: JANNA COLLECCHI
Title or Position: OFFICE MANAGER
Credential:
Phone: 253-939-0700