Healthcare Provider Details

I. General information

NPI: 1790009207
Provider Name (Legal Business Name): ENDO NW BELLEVUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2010
Last Update Date: 03/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 116TH AVE NE SUITE 102
BELLEVUE WA
98004-3813
US

IV. Provider business mailing address

1545 116TH AVE NE SUITE 102
BELLEVUE WA
98004-3813
US

V. Phone/Fax

Practice location:
  • Phone: 425-454-4582
  • Fax: 425-646-9430
Mailing address:
  • Phone: 425-454-4582
  • Fax: 425-646-9430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number4517
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number7999
License Number StateWA

VIII. Authorized Official

Name: DR. KEVIN Y CHOI
Title or Position: OWNER
Credential: D.M.D.
Phone: 425-454-4582