=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629498407
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL A SACRO DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2014
-----------------------------------------------------
Last Update Date | 04/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6004 PORTAL WAY UNIT A
-----------------------------------------------------
City | FERNDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98248-8382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-384-3440
-----------------------------------------------------
Fax | 360-384-6028
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6004 PORTAL WAY UNIT A
-----------------------------------------------------
City | FERNDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98248-8382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-384-3440
-----------------------------------------------------
Fax | 360-384-6028
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/DENTIST
-----------------------------------------------------
Name | MICHAEL A SACRO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 360-384-3440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 60453211
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------