Healthcare Provider Details

I. General information

NPI: 1689659245
Provider Name (Legal Business Name): PETER D. AGNOS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

931 PACIFIC AVE
EVERETT WA
98201-4146
US

IV. Provider business mailing address

931 PACIFIC AVE
EVERETT WA
98201-4146
US

V. Phone/Fax

Practice location:
  • Phone: 425-252-1136
  • Fax: 425-259-1235
Mailing address:
  • Phone: 425-252-1136
  • Fax: 425-259-1235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDE00004468
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: