Healthcare Provider Details

I. General information

NPI: 1922359744
Provider Name (Legal Business Name): LEGACY DENTAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2012
Last Update Date: 09/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9951 MICKELBERRY RD NW SUITE #215
SILVERDALE WA
98383-8309
US

IV. Provider business mailing address

9951 MICKELBERRY RD NW SUITE #215
SILVERDALE WA
98383-8309
US

V. Phone/Fax

Practice location:
  • Phone: 360-692-9701
  • Fax:
Mailing address:
  • Phone: 360-692-9701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. BRIAN V KERR
Title or Position: OWNER
Credential: DMD
Phone: 253-584-6200