Healthcare Provider Details

I. General information

NPI: 1356436315
Provider Name (Legal Business Name): WALLY W. KEGEL D.D.S., M.S.D., P.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 OLIVE WAY SUITE 627
SEATTLE WA
98101-1761
US

IV. Provider business mailing address

509 OLIVE WAY SUITE 627
SEATTLE WA
98101-1761
US

V. Phone/Fax

Practice location:
  • Phone: 206-682-9269
  • Fax: 206-624-4140
Mailing address:
  • Phone: 206-682-9269
  • Fax: 206-624-4140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDE00004873
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: