=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801009014
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAFAEL DINO DIMAYUGA DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3533 172ND ST NE BLDG B
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-658-3000
-----------------------------------------------------
Fax | 360-653-1560
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8817 123RD LN NE
-----------------------------------------------------
City | KIRKLAND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98033-5876
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-658-3000
-----------------------------------------------------
Fax | 360-653-1560
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DE00010388
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------