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General NPI Number Information
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NPI Number | 1265088041
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Entity Type | Organization
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Legal Business Name | NATE REPTA DMD PS
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Dates
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Enumeration Date | 08/16/2019
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Last Update Date | 08/16/2019
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Provider Practice Location Address
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Address Line | 275 PENDLETON WAY
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City | WASHOUGAL
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State | WA
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Zip | 98671-4203
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Country | US
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Telephone | 503-453-3641
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Fax |
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Provider Business Mailing Address
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Address Line | 693 32ND ST UNIT 5
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City | WASHOUGAL
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State | WA
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Zip | 98671-1865
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | SHAREHOLDER
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Name | NATE REPTA
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Credential | DMD
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Telephone | 503-453-3641
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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