MEDICARE: DR. WALLY W. KEGEL D.D.S., M.S.D., P.S.

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	1223P0300X	Periodontics	DE00004873	WA

General Provider Information

NPI Number	:	1356436315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WALLY W. KEGEL D.D.S., M.S.D., P.S.

Provider Business Mailing Address
First Line	:	509 OLIVE WAY
Second Line	:	SUITE 627
City	:	SEATTLE
State	:	WA
Zip	:	98101-1761
Country	:	US
Telephone Number	:	206-682-9269
Fax Number	:	206-624-4140

Provider Business Practice Location Address
First Line	:	509 OLIVE WAY
Second Line	:	SUITE 627
City	:	SEATTLE
State	:	WA
Zip	:	98101-1761
Country	:	US
Telephone Number	:	206-682-9269
Fax Number	:	206-624-4140

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	07/08/2007

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