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General NPI Number Information
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NPI Number | 1477548766
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Entity Type | Individual
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Provider Name | DEREK T PAWLAK LD
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Gender | Male
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Dates
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Enumeration Date | 09/13/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 161 BAY LYN DR
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City | LYNDEN
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State | WA
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Zip | 98264-9404
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Country | US
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Telephone | 360-318-0880
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Fax | 360-318-0880
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Provider Business Mailing Address
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Address Line | 161 BAY LYN DR
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City | LYNDEN
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State | WA
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Zip | 98264-9404
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Country | US
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Telephone | 360-318-0880
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Fax | 360-318-0880
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122400000X
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Taxonomy Name | Denturist
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License Number | 025108DN00000270
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License Number State | WA
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