Healthcare Provider Details

I. General information

NPI: 1285518399
Provider Name (Legal Business Name): JONATHAN MYLES LARA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2025
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3910 MARTIN WAY E STE A
OLYMPIA WA
98506-5220
US

IV. Provider business mailing address

8012 112TH STREET CT E STE 320
PUYALLUP WA
98373-7856
US

V. Phone/Fax

Practice location:
  • Phone: 360-459-1333
  • Fax:
Mailing address:
  • Phone: 253-848-2331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number70022845
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: