Healthcare Provider Details

I. General information

NPI: 1962897504
Provider Name (Legal Business Name): BRIAN DIAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2015
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12039 NE 128TH ST STE 500
KIRKLAND WA
98034-3029
US

IV. Provider business mailing address

12039 NE 128TH ST STE 500
KIRKLAND WA
98034-3029
US

V. Phone/Fax

Practice location:
  • Phone: 425-899-4930
  • Fax: 425-899-4811
Mailing address:
  • Phone: 254-899-4930
  • Fax: 425-899-4811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number2020010618
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number61150713
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: