MEDICARE: KELLEY M. WASHINGTON DDS,PS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	9721	WA

General Provider Information

NPI Number	:	1174826937
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELLEY M. WASHINGTON DDS,PS

Provider Business Mailing Address
First Line	:	4543 RAINIER AVE S
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98118-1656
Country	:	US
Telephone Number	:	206-722-8211
Fax Number	:	206-722-3249

Provider Business Practice Location Address
First Line	:	4543 RAINIER AVE S
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98118-1656
Country	:	US
Telephone Number	:	206-722-8211
Fax Number	:	206-722-3249

Authorized Official
Title or Position	:	PRESIDENT/DENTIST
Name	:	DR. KELLEY MICHAEL WASHINGTON
Credential	:	DDS
Telephone Number	:	206-722-8211

Provider Enumeration Date	:	12/15/2010
Last Update Date	:	12/15/2010

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