Healthcare Provider Details

I. General information

NPI: 1942279997
Provider Name (Legal Business Name): EDMONDS BAY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 W DAYTON SUITE 301
EDMONDS WA
98020
US

IV. Provider business mailing address

51 W DAYTON SUITE 301
EDMONDS WA
98020
US

V. Phone/Fax

Practice location:
  • Phone: 425-775-5162
  • Fax: 425-491-8100
Mailing address:
  • Phone: 425-775-5162
  • Fax: 425-491-8100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE0010360
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE00005091
License Number StateWA

VIII. Authorized Official

Name: DR. JAMES V MISCHEL
Title or Position: OWNER
Credential: DDS
Phone: 425-775-5162