Provider Demographics
NPI:1326500109
Name:DI SABELLA, MILES RICHARD
Entity Type:Individual
Prefix:
First Name:MILES
Middle Name:RICHARD
Last Name:DI SABELLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 POWELL AVE SW
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-2908
Mailing Address - Country:US
Mailing Address - Phone:425-277-1311
Mailing Address - Fax:
Practice Address - Street 1:126 AUBURN AVE STE 100
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-5082
Practice Address - Country:US
Practice Address - Phone:142-527-7131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE610671301223G0001X, 122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program