MEDICARE: THE MILL CREEK DENTIST

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	1223G0001X	General Practice Dentistry	DE00005339	WA

General Provider Information

NPI Number	:	1205209913
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE MILL CREEK DENTIST

Provider Business Mailing Address
First Line	:	16306 BOTHELL EVERETT HWY
Second Line	:	SUITE B
City	:	MILL CREEK
State	:	WA
Zip	:	98012-1283
Country	:	US
Telephone Number	:	425-745-4661
Fax Number	:	425-491-7077

Provider Business Practice Location Address
First Line	:	16306 BOTHELL EVERETT HWY
Second Line	:	SUITE B
City	:	MILL CREEK
State	:	WA
Zip	:	98012-1283
Country	:	US
Telephone Number	:	425-745-4661
Fax Number	:	425-491-7077

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KIM A WALTER
Credential	:	DDS
Telephone Number	:	425-745-4661

Provider Enumeration Date	:	11/03/2015
Last Update Date	:	11/03/2015

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