Healthcare Provider Details

I. General information

NPI: 1346636263
Provider Name (Legal Business Name): PHAM WALTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2015
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12138 MUKILTEO SPEEDWAY STE 301
MUKILTEO WA
98275-5738
US

IV. Provider business mailing address

12138 MUKILTEO SPEEDWAY STE 301
MUKILTEO WA
98275-5738
US

V. Phone/Fax

Practice location:
  • Phone: 425-347-4141
  • Fax:
Mailing address:
  • Phone: 425-347-4141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE00008539
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW HERNANDEZ
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 425-347-4141