Healthcare Provider Details

I. General information

NPI: 1851726368
Provider Name (Legal Business Name): GARY ELDON HEYAMOTO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2013
Last Update Date: 09/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1729 208TH ST SE STE 101
BOTHELL WA
98012-7789
US

IV. Provider business mailing address

1729 208TH ST SE STE 101
BOTHELL WA
98012-7789
US

V. Phone/Fax

Practice location:
  • Phone: 425-485-8885
  • Fax: 425-485-8341
Mailing address:
  • Phone: 425-485-8885
  • Fax: 425-485-8341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5433
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. GARY ELDON HEYAMOTO
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 425-485-8885