Provider Demographics
NPI:1083705800
Name:CASTILLO, SAMUEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:CASTILLO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14703 1ST LANE NE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:DUVALL
Mailing Address - State:WA
Mailing Address - Zip Code:98019
Mailing Address - Country:US
Mailing Address - Phone:425-788-2626
Mailing Address - Fax:425-788-7805
Practice Address - Street 1:14703 1ST LANE NE
Practice Address - Street 2:SUITE 203
Practice Address - City:DUVALL
Practice Address - State:WA
Practice Address - Zip Code:98019
Practice Address - Country:US
Practice Address - Phone:425-788-2626
Practice Address - Fax:425-788-7805
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA52301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5547906Medicaid