Healthcare Provider Details

I. General information

NPI: 1659940468
Provider Name (Legal Business Name): PSPD - EVERETT, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3224 COLBY AVE STE A
EVERETT WA
98201-4383
US

IV. Provider business mailing address

3224 COLBY AVE STE A
EVERETT WA
98201-4383
US

V. Phone/Fax

Practice location:
  • Phone: 425-259-3505
  • Fax:
Mailing address:
  • Phone: 425-259-3505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JESSICA KNIGHT
Title or Position: CREDENTIAL MANAGER
Credential:
Phone: 360-659-8100