Healthcare Provider Details

I. General information

NPI: 1326044058
Provider Name (Legal Business Name): ER-JIA MAO DDS, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 N NORTHGATE WAY STE 215
SEATTLE WA
98133-9018
US

IV. Provider business mailing address

2111 N NORTHGATE WAY STE 215
SEATTLE WA
98133
US

V. Phone/Fax

Practice location:
  • Phone: 206-367-6767
  • Fax: 206-367-4788
Mailing address:
  • Phone: 206-367-6767
  • Fax: 206-367-4788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDE8464
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: