Healthcare Provider Details

I. General information

NPI: 1215970413
Provider Name (Legal Business Name): GREGORY BRUCE MORENSEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14645 BEL RED RD SUITE 100
BELLEVUE WA
98007
US

IV. Provider business mailing address

14645 BEL RED RD SUITE 100
BELLEVUE WA
98007
US

V. Phone/Fax

Practice location:
  • Phone: 425-644-2205
  • Fax: 425-644-1564
Mailing address:
  • Phone: 425-644-2205
  • Fax: 425-644-1564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4778
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: