Healthcare Provider Details

I. General information

NPI: 1942397435
Provider Name (Legal Business Name): CHARLES R ANDEREGG JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 07/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14655 BEL RED RD SUITE 202
BELLEVUE WA
98007-3900
US

IV. Provider business mailing address

14655 BEL RED RD SUITE 202
BELLEVUE WA
98007-3900
US

V. Phone/Fax

Practice location:
  • Phone: 425-747-7007
  • Fax: 425-747-7342
Mailing address:
  • Phone: 425-747-7007
  • Fax: 425-747-7342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDE00006833
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: