=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255695755
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL MCDADE, D.D.S.,P.L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2012
-----------------------------------------------------
Last Update Date | 06/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1710 LAFAYETTE ST
-----------------------------------------------------
City | STEILACOOM
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98388-1328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-582-3106
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1710 LAFAYETTE ST
-----------------------------------------------------
City | STEILACOOM
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98388-1328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-582-3106
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DOCTOR
-----------------------------------------------------
Name | DR. MICHAEL EDWARD MCDADE
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 253-582-3106
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 00006051
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------