=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326153206
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRENT M ROBINSON DDS PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19108 33RD AVE W STE B
-----------------------------------------------------
City | LYNNWOOD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98036-4728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-778-1164
-----------------------------------------------------
Fax | 425-771-7836
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19108 33RD AVE W STE B
-----------------------------------------------------
City | LYNNWOOD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98036-4728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-778-1164
-----------------------------------------------------
Fax | 425-771-7836
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRENT MICHAEL ROBINSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 425-778-1164
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 9394
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------