Healthcare Provider Details

I. General information

NPI: 1457656290
Provider Name (Legal Business Name): MICHAEL DAVID SPEKTOR PERIODONTIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2011
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 116TH AVE NE SUITE 100
BELLEVUE WA
98004-3813
US

IV. Provider business mailing address

1545 116TH AVE NE SUITE 100
BELLEVUE WA
98004-3813
US

V. Phone/Fax

Practice location:
  • Phone: 425-454-1322
  • Fax: 425-450-0179
Mailing address:
  • Phone: 425-454-1322
  • Fax: 425-450-0179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDE 00005329
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: