Healthcare Provider Details

I. General information

NPI: 1477013233
Provider Name (Legal Business Name): RAPHAEL HUNTLEY D.D.S., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 07/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 9TH AVE
SEATTLE WA
98104-2420
US

IV. Provider business mailing address

2905 PRINCETON AVE
SAINT LOUIS PARK MN
55416-1956
US

V. Phone/Fax

Practice location:
  • Phone: 206-520-5000
  • Fax:
Mailing address:
  • Phone: 916-233-6352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDR60949163
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: