Healthcare Provider Details

I. General information

NPI: 1073683074
Provider Name (Legal Business Name): THERON ANGUS MANSON I DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9750 NE 120TH PL #8
KIRKLAND WA
98034-4207
US

IV. Provider business mailing address

9750 NE 120TH PL #8
KIRKLAND WA
98034-4207
US

V. Phone/Fax

Practice location:
  • Phone: 425-823-1909
  • Fax: 425-823-8969
Mailing address:
  • Phone: 425-823-1909
  • Fax: 425-823-8969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9434
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE00009434
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: