MEDICARE: DR. KELLEY MICHAEL WASHINGTON DDS

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	9721	WA

General Provider Information

NPI Number	:	1578866406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLEY MICHAEL WASHINGTON DDS

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	:
Name	:
Credential	:
Telephone Number	:

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

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