Provider Demographics
NPI:1083714877
Name:ORTHODONTIC ASSOCIATES OF MERCER ISLAND
Entity Type:Organization
Organization Name:ORTHODONTIC ASSOCIATES OF MERCER ISLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MCNEILL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:206-232-9600
Mailing Address - Street 1:2817 80TH AVENUE SE
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-2913
Mailing Address - Country:US
Mailing Address - Phone:206-232-9600
Mailing Address - Fax:206-232-2936
Practice Address - Street 1:2817 80TH AVENUE SE
Practice Address - Street 2:
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040-2913
Practice Address - Country:US
Practice Address - Phone:206-232-9600
Practice Address - Fax:206-232-2936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA32541223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6809OtherLICENSE NUMBER
WA3254OtherLICENSE NUMBER