Healthcare Provider Details

I. General information

NPI: 1174826937
Provider Name (Legal Business Name): KELLEY M. WASHINGTON DDS,PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2010
Last Update Date: 12/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4543 RAINIER AVE S
SEATTLE WA
98118-1656
US

IV. Provider business mailing address

4543 RAINIER AVE S
SEATTLE WA
98118-1656
US

V. Phone/Fax

Practice location:
  • Phone: 206-722-8211
  • Fax: 206-722-3249
Mailing address:
  • Phone: 206-722-8211
  • Fax: 206-722-3249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number9721
License Number StateWA

VIII. Authorized Official

Name: DR. KELLEY MICHAEL WASHINGTON
Title or Position: PRESIDENT/DENTIST
Credential: DDS
Phone: 206-722-8211