Provider Demographics
NPI:1134458367
Name:ARDIZZONE, JOSEPH C (DDS)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:C
Last Name:ARDIZZONE
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 1:30317 16TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-4124
Mailing Address - Country:US
Mailing Address - Phone:253-839-7270
Mailing Address - Fax:253-941-1336
Practice Address - Street 1:30317 16TH AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-4124
Practice Address - Country:US
Practice Address - Phone:253-839-7270
Practice Address - Fax:253-941-1336
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-17
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6193122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91-1594091OtherTAX ID #