Healthcare Provider Details

I. General information

NPI: 1699839589
Provider Name (Legal Business Name): JEFFREY C HSU D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 TERRA EDEN ST
FORKS WA
98331-9604
US

IV. Provider business mailing address

430 TERRA EDEN ST
FORKS WA
98331-9604
US

V. Phone/Fax

Practice location:
  • Phone: 360-374-6868
  • Fax: 360-374-3870
Mailing address:
  • Phone: 360-374-6868
  • Fax: 360-374-3870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE00010147
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: