MEDICARE: DR. RANDALL M. MAEBO D.D.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	122300000X	Dentist	6372	WA

General Provider Information

NPI Number	:	1780754820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDALL M. MAEBO D.D.S.

Provider Business Mailing Address
First Line	:	14030 NE 24TH ST
Second Line	:	SUITE 103
City	:	BELLEVUE
State	:	WA
Zip	:	98007-3724
Country	:	US
Telephone Number	:	425-644-8485
Fax Number	:	425-644-8420

Provider Business Practice Location Address
First Line	:	14030 NE 24TH ST
Second Line	:	SUITE 103
City	:	BELLEVUE
State	:	WA
Zip	:	98007-3724
Country	:	US
Telephone Number	:	425-644-8485
Fax Number	:	425-644-8420

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

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	07/08/2007

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