Provider Demographics
NPI:1326692013
Name:NI, GENTAI (DDS)
Entity Type:Individual
Prefix:
First Name:GENTAI
Middle Name:
Last Name:NI
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 1:20639 STATE ROUTE 410 E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-8461
Mailing Address - Country:US
Mailing Address - Phone:253-862-0194
Mailing Address - Fax:253-862-9068
Practice Address - Street 1:20639 STATE ROUTE 410 E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-8461
Practice Address - Country:US
Practice Address - Phone:253-862-0194
Practice Address - Fax:253-862-9068
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-30
Last Update Date:2021-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE61007817122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentistGroup - Multi-Specialty