Healthcare Provider Details

I. General information

NPI: 1487656518
Provider Name (Legal Business Name): MICHAEL E. KONDO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4610 N ASH ST STE 201
SPOKANE WA
99205-1482
US

IV. Provider business mailing address

4610 N ASH ST STE 201
SPOKANE WA
99205-1482
US

V. Phone/Fax

Practice location:
  • Phone: 509-325-4313
  • Fax: 509-325-3919
Mailing address:
  • Phone: 509-325-4313
  • Fax: 509-325-3919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4945
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: