Healthcare Provider Details

I. General information

NPI: 1558655886
Provider Name (Legal Business Name): BRANDON LADOUX D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2011
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N TRIBAL CENTER RD
SKOKOMISH NATION WA
98584-9748
US

IV. Provider business mailing address

100 N TRIBAL CENTER RD
SKOKOMISH NATION WA
98584-9748
US

V. Phone/Fax

Practice location:
  • Phone: 360-426-5755
  • Fax:
Mailing address:
  • Phone: 360-426-5755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE 60214111
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: