Healthcare Provider Details

I. General information

NPI: 1619037157
Provider Name (Legal Business Name): FAIRWOOD ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 08/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14300 SE PETROVITSKY ROAD
RENTON WA
98058
US

IV. Provider business mailing address

14300 SE PETROVITSKY ROAD
RENTON WA
98058
US

V. Phone/Fax

Practice location:
  • Phone: 425-235-8800
  • Fax: 425-235-0288
Mailing address:
  • Phone: 425-235-8800
  • Fax: 425-235-0288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDE00008957
License Number StateWA

VIII. Authorized Official

Name: MARIO D CHORAK
Title or Position: ORTHODONTIST OWNER
Credential: DMD
Phone: 425-235-8800