Provider Demographics
NPI:1114938313
Name:TETRICK, GARY M (DDS PS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:TETRICK
Suffix:
Gender:M
Credentials:DDS PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3628 MERIDIAN ST
Mailing Address - Street 2:STE 1-C
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225
Mailing Address - Country:US
Mailing Address - Phone:360-734-4374
Mailing Address - Fax:360-715-9196
Practice Address - Street 1:3628 MERIDIAN ST
Practice Address - Street 2:STE 1-C
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225
Practice Address - Country:US
Practice Address - Phone:360-734-4374
Practice Address - Fax:360-715-9196
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE0000455Z1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5514005Medicaid