=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417063280
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONALD EDWARD NIEMANN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 408 LILLY RD NE STE B
-----------------------------------------------------
City | OLYMPIA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98506-6954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-459-5900
-----------------------------------------------------
Fax | 360-459-8720
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 408 LILLY RD NE STE B
-----------------------------------------------------
City | OLYMPIA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98506-6954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-459-5900
-----------------------------------------------------
Fax | 360-459-8720
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 4384
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------