Healthcare Provider Details

I. General information

NPI: 1083817878
Provider Name (Legal Business Name): ANDREW P. WIGHTMAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 12/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6050 TACOMA MALL BLVD SUITE 330
TOCOMA WA
98409
US

IV. Provider business mailing address

6050 TACOMA MALL BLVD, SUITE 330
TOCOMA WA
98409
US

V. Phone/Fax

Practice location:
  • Phone: 253-473-0651
  • Fax: 253-444-0761
Mailing address:
  • Phone: 253-473-0651
  • Fax: 253-444-0761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDE60325350
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: