Healthcare Provider Details

I. General information

NPI: 1467589952
Provider Name (Legal Business Name): ANGEL LUIS AVILES D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14655 BEL RED RD SUITE 201
BELLEVUE WA
98007-3900
US

IV. Provider business mailing address

14655 BEL RED RD SUITE 201
BELLEVUE WA
98007-3900
US

V. Phone/Fax

Practice location:
  • Phone: 425-614-3636
  • Fax: 425-614-1074
Mailing address:
  • Phone: 425-614-3636
  • Fax: 425-614-1074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDE00009775
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: