Provider Demographics
NPI:1073683074
Name:MANSON, THERON ANGUS I (DDS)
Entity Type:Individual
Prefix:
First Name:THERON
Middle Name:ANGUS
Last Name:MANSON
Suffix:I
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 1:9750 NE 120TH PL #8
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-4207
Mailing Address - Country:US
Mailing Address - Phone:425-823-1909
Mailing Address - Fax:425-823-8969
Practice Address - Street 1:9750 NE 120TH PL #8
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-4207
Practice Address - Country:US
Practice Address - Phone:425-823-1909
Practice Address - Fax:425-823-8969
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000094341223G0001X
WA9434122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5047998Medicaid