=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497555080
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHILIP A WALCZAK DDS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2025
-----------------------------------------------------
Last Update Date | 05/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9730 3RD AVE NE STE 105
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98115-2023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-350-8479
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12334 31ST AVE NE APT 608
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98125-5583
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PHILIP ADAM WALCZAK
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 425-350-8479
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------