Healthcare Provider Details

I. General information

NPI: 1770381543
Provider Name (Legal Business Name): ZACHARY CHASE WHITTAKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2025
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 S COOLIDGE ST
MOSES LAKE WA
98837-1873
US

IV. Provider business mailing address

13511 TERRACE CREEK DR APT 200
LOUISVILLE KY
40245-5845
US

V. Phone/Fax

Practice location:
  • Phone: 509-765-0674
  • Fax:
Mailing address:
  • Phone: 801-367-2465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE70005087
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: