Healthcare Provider Details

I. General information

NPI: 1306594981
Provider Name (Legal Business Name): RUSSELL A DEAL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2022
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 112TH AVE NE STE C110
BELLEVUE WA
98004-3737
US

IV. Provider business mailing address

1200 112TH AVE NE
BELLEVUE WA
98004-3732
US

V. Phone/Fax

Practice location:
  • Phone: 425-214-4746
  • Fax:
Mailing address:
  • Phone: 425-214-4746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDE61260400
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: