Healthcare Provider Details

I. General information

NPI: 1720292436
Provider Name (Legal Business Name): SAMUEL LOUIS BOBEK DMD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 02/29/2020
Certification Date: 02/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 BROADWAY STE 460
SEATTLE WA
98122-5312
US

IV. Provider business mailing address

600 BROADWAY STE 460
SEATTLE WA
98122-5312
US

V. Phone/Fax

Practice location:
  • Phone: 206-207-1525
  • Fax: 206-207-1625
Mailing address:
  • Phone: 206-207-1525
  • Fax: 206-207-1625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberMD60495614
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDE60497405
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: