Healthcare Provider Details

I. General information

NPI: 1720058746
Provider Name (Legal Business Name): MICHELLE DIANE DULLANTY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE DIANE PETERSEN DDS

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 E DALKE AVE
SPOKANE WA
99208-8112
US

IV. Provider business mailing address

611 N IRON BRIDGE WAY
SPOKANE WA
99202-4932
US

V. Phone/Fax

Practice location:
  • Phone: 509-444-8200
  • Fax: 509-984-1197
Mailing address:
  • Phone: 509-444-8888
  • Fax: 509-444-7806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE00010510
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-3457
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: