Healthcare Provider Details

I. General information

NPI: 1790132041
Provider Name (Legal Business Name): NICHOLAS PARQUE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4915 25TH AVE NE
SEATLLE WA
98105
US

IV. Provider business mailing address

1200 12TH AVE S STE 901
SEATTLE WA
98144-2712
US

V. Phone/Fax

Practice location:
  • Phone: 206-524-1600
  • Fax:
Mailing address:
  • Phone: 206-548-3114
  • Fax: 206-262-0859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number60650656
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: