Healthcare Provider Details

I. General information

NPI: 1326431479
Provider Name (Legal Business Name): BRADEN H GISWOLD DDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2015
Last Update Date: 03/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742 CAMANO AVE STE 101A
LANGLEY WA
98260-9570
US

IV. Provider business mailing address

742 CAMANO AVE STE 101A
LANGLEY WA
98260-9570
US

V. Phone/Fax

Practice location:
  • Phone: 360-221-6373
  • Fax: 360-221-6375
Mailing address:
  • Phone: 360-221-6373
  • Fax: 360-221-6375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60172172
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. BRADEN HIROSHI GISWOLD
Title or Position: OWNER
Credential: D.D.S.
Phone: 360-221-6373