=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376808402
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SILAS D. DUDLEY, D.D.S., M.S.D., P.L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2012
-----------------------------------------------------
Last Update Date | 07/04/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10920 SE 208TH ST
-----------------------------------------------------
City | KENT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98031-4009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-852-7331
-----------------------------------------------------
Fax | 253-813-3826
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10920 SE 208TH ST
-----------------------------------------------------
City | KENT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98031-4009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-852-7331
-----------------------------------------------------
Fax | 253-813-3826
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SILAS D DUDLEY
-----------------------------------------------------
Credential | DDS, MSD
-----------------------------------------------------
Telephone | 206-992-5098
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DE60231571
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------