Healthcare Provider Details

I. General information

NPI: 1952045742
Provider Name (Legal Business Name): ANDY ANDREYEVICH SHIMCHUK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2022
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 N 5TH AVE
SEQUIM WA
98382-3079
US

IV. Provider business mailing address

550 N 5TH AVE
SEQUIM WA
98382-3079
US

V. Phone/Fax

Practice location:
  • Phone: 360-681-0900
  • Fax:
Mailing address:
  • Phone: 360-681-0900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019.033860
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDENT.DE.70082594
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: