Healthcare Provider Details

I. General information

NPI: 1992470827
Provider Name (Legal Business Name): PAVEL TERESHCHUK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2021
Last Update Date: 08/20/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4111 ALDERWOOD MALL BLVD
LYNNWOOD WA
98036-6765
US

IV. Provider business mailing address

10829 87TH AVE NE
MARYSVILLE WA
98271-7629
US

V. Phone/Fax

Practice location:
  • Phone: 425-249-0771
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH61098804
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: