Provider Demographics
NPI:1275785719
Name:GATEWAY FAMILY DENTISTRY AT MILL CREEK
Entity Type:Organization
Organization Name:GATEWAY FAMILY DENTISTRY AT MILL CREEK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:FLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-338-2966
Mailing Address - Street 1:13416 BOTHELL EVERETT HWY
Mailing Address - Street 2:SUITE 207
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-5311
Mailing Address - Country:US
Mailing Address - Phone:425-338-2966
Mailing Address - Fax:
Practice Address - Street 1:13416 BOTHELL EVERETT HWY
Practice Address - Street 2:SUITE 207
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-5311
Practice Address - Country:US
Practice Address - Phone:425-338-2966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6701261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental