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General NPI Number Information
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NPI Number | 1275785719
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Entity Type | Organization
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Legal Business Name | GATEWAY FAMILY DENTISTRY AT MILL CREEK
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Dates
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Enumeration Date | 10/15/2008
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Last Update Date | 10/15/2008
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Provider Practice Location Address
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Address Line | 13416 BOTHELL EVERETT HWY SUITE 207
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City | MILL CREEK
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State | WA
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Zip | 98012-5311
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Country | US
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Telephone | 425-338-2966
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Fax |
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Provider Business Mailing Address
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Address Line | 13416 BOTHELL EVERETT HWY SUITE 207
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City | MILL CREEK
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State | WA
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Zip | 98012-5311
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Country | US
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Telephone | 425-338-2966
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Fax |
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Authorized Official
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Title or Position | OWNER/ SOLE PROPRIETOR
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Name | DR. ROGER ALLEN FLAKE
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Credential | DDS
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Telephone | 425-338-2966
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 6701
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License Number State | WA
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