Healthcare Provider Details

I. General information

NPI: 1982756920
Provider Name (Legal Business Name): ROBERT MARTIN GOTTLIEB DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5723 NE BOTHELL WAY SUITE C
KENMORE WA
98028
US

IV. Provider business mailing address

5723 NE BOTHELL WAY SUITE C
KENMORE WA
98028
US

V. Phone/Fax

Practice location:
  • Phone: 425-486-9111
  • Fax: 425-489-1923
Mailing address:
  • Phone: 425-486-9111
  • Fax: 425-489-1923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number5424
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: