Healthcare Provider Details

I. General information

NPI: 1407461270
Provider Name (Legal Business Name): CRISAFULLI DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18920 BOTHELL WAY NE STE 200
BOTHELL WA
98011-1981
US

IV. Provider business mailing address

18920 BOTHELL WAY NE STE 200
BOTHELL WA
98011-1981
US

V. Phone/Fax

Practice location:
  • Phone: 425-483-5838
  • Fax:
Mailing address:
  • Phone: 425-483-5838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: WENDY CRISAFULLI
Title or Position: OWNER/DENTIST
Credential:
Phone: 425-483-5838