Healthcare Provider Details

I. General information

NPI: 1417163635
Provider Name (Legal Business Name): SILVER FALLS DERMATOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11011 MERIDIAN AVE N SUITE 102
SEATTLE WA
98133-8967
US

IV. Provider business mailing address

PO BOX 741825
LOS ANGELES CA
90074-1825
US

V. Phone/Fax

Practice location:
  • Phone: 206-859-5777
  • Fax: 206-859-5776
Mailing address:
  • Phone: 206-859-5777
  • Fax: 206-859-5776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberMD00042289
License Number StateWA

VIII. Authorized Official

Name: MALISSA KOBBEVIK
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 360-375-2038