Provider Demographics
NPI:1093813800
Name:ETHEREDGE, PHILIP J (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:J
Last Name:ETHEREDGE
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 1:13118 121ST WAY NE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034
Mailing Address - Country:US
Mailing Address - Phone:425-822-0505
Mailing Address - Fax:425-825-5661
Practice Address - Street 1:13118 121ST WAY NE
Practice Address - Street 2:SUITE 102
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034
Practice Address - Country:US
Practice Address - Phone:425-822-0505
Practice Address - Fax:425-825-5661
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice