Healthcare Provider Details

I. General information

NPI: 1437944857
Provider Name (Legal Business Name): ANDREW MARK NORDLIE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 04/19/2025
Certification Date: 04/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 S 320TH ST STE 330
FEDERAL WAY WA
98003-5461
US

IV. Provider business mailing address

21421 SNAG ISLAND DR E
LAKE TAPPS WA
98391-8709
US

V. Phone/Fax

Practice location:
  • Phone: 206-400-0800
  • Fax:
Mailing address:
  • Phone: 253-561-2294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDE61661757
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: