Provider Demographics
NPI:1023194701
Name:TRAUTMAN, PHILLIPS B (DDS)
Entity Type:Individual
Prefix:
First Name:PHILLIPS
Middle Name:B
Last Name:TRAUTMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4164 MERIDIAN ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-5583
Mailing Address - Country:US
Mailing Address - Phone:360-676-8822
Mailing Address - Fax:360-676-7488
Practice Address - Street 1:4164 MERIDIAN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-5583
Practice Address - Country:US
Practice Address - Phone:360-676-8822
Practice Address - Fax:360-676-7488
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000054941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5044672Medicaid
WA3872TROtherREGENCE BLUE SHIELD
WA0174916OtherSTATE LABOR AND INDUSTRIE