Healthcare Provider Details

I. General information

NPI: 1942618251
Provider Name (Legal Business Name): GARY BLYLEVEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2014
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 LINCOLN STREET 2ND FLOOR
TACOMA WA
98431-0001
US

IV. Provider business mailing address

9900 LINCOLN STREET 2ND FLOOR
TACOMA WA
98431-0001
US

V. Phone/Fax

Practice location:
  • Phone: 253-967-5271
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD-4574
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: