Healthcare Provider Details

I. General information

NPI: 1700948551
Provider Name (Legal Business Name): PAUL B GREENAWALT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9576 RIDGETOP BLVD NW #103
SILVERDALE WA
98383-8554
US

IV. Provider business mailing address

PO BOX 3770
SILVERDALE WA
98383-3770
US

V. Phone/Fax

Practice location:
  • Phone: 360-698-9335
  • Fax: 360-698-9385
Mailing address:
  • Phone: 360-698-9335
  • Fax: 360-698-9385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number8080
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: