Provider Demographics
NPI:1255483053
Name:JORG, GRETCHEN (DDS)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:JORG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6319 24TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-2423
Mailing Address - Country:US
Mailing Address - Phone:206-784-7171
Mailing Address - Fax:206-781-5079
Practice Address - Street 1:6319 24TH AVE NW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-2423
Practice Address - Country:US
Practice Address - Phone:206-784-7171
Practice Address - Fax:206-781-5079
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000103041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice