=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295068468
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. ERAN J. GUTKIN DMD PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2009
-----------------------------------------------------
Last Update Date | 01/31/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3203 W MCGRAW ST SUITE 201
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98199-3236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-283-0964
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3203 W MCGRAW ST 201
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98199-3236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-283-0964
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ERAN JAMES GUTKIN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 206-283-0964
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | DE60102369
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------