Healthcare Provider Details

I. General information

NPI: 1487008462
Provider Name (Legal Business Name): HIRUY GEBREWOLD RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2016
Last Update Date: 04/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1019 112TH ST SW
EVERETT WA
98204-4875
US

IV. Provider business mailing address

1019 112TH ST SW
EVERETT WA
98204-4875
US

V. Phone/Fax

Practice location:
  • Phone: 425-551-6001
  • Fax: 425-551-6009
Mailing address:
  • Phone: 425-551-6001
  • Fax: 425-551-6009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH 60205570
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: