MEDICARE: EAGLE FAMILY DENTAL CENTER

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	DE00006048	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DE00007379	OTHER	WA	STATE OF WASH LICENSE
2	DE00006048	OTHER	WV	STATE OF WASHINGTON LICEN

General Provider Information

NPI Number	:	1801806898
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAGLE FAMILY DENTAL CENTER

Provider Business Mailing Address
First Line	:	20210 77TH AVE NE
Second Line	:
City	:	ARLINGTON
State	:	WA
Zip	:	98223-4602
Country	:	US
Telephone Number	:	360-435-2151
Fax Number	:	360-435-7845

Provider Business Practice Location Address
First Line	:	20210 77TH AVE NE
Second Line	:
City	:	ARLINGTON
State	:	WA
Zip	:	98223-4602
Country	:	US
Telephone Number	:	360-435-2151
Fax Number	:	360-435-7845

Authorized Official
Title or Position	:	DOCTOR/OWNER
Name	:	DR. JEFFREY D. HULEATT
Credential	:	D.D.S.
Telephone Number	:	360-435-2151

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	08/22/2020

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Directions to “EAGLE FAMILY DENTAL CENTER ” Practice Location

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