Healthcare Provider Details

I. General information

NPI: 1164815569
Provider Name (Legal Business Name): JOSEPH GARCIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 07/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 EASTLAKE AVE E APT 208
SEATTLE WA
98102-2003
US

IV. Provider business mailing address

2960 EASTLAKE AVE E APT 208
SEATTLE WA
98102-2003
US

V. Phone/Fax

Practice location:
  • Phone: 619-405-0894
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number60555369
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: