Healthcare Provider Details

I. General information

NPI: 1174725758
Provider Name (Legal Business Name): RANDALL HEISUKE OGATA DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3216 NE 45TH PLACE SUITE 300WW
SEATTLE WA
98105-4028
US

IV. Provider business mailing address

3216 NE 45TH PLACE SUITE 300WW
SEATTLE WA
98105-4028
US

V. Phone/Fax

Practice location:
  • Phone: 206-523-3322
  • Fax: 206-522-2512
Mailing address:
  • Phone: 206-523-3322
  • Fax: 206-522-2512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDE00006929
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: