Provider Demographics
NPI:1437746088
Name:GUSAK, PAVLO BOHDAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAVLO
Middle Name:BOHDAN
Last Name:GUSAK
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 1:1461 52ND ST NE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-1227
Mailing Address - Country:US
Mailing Address - Phone:206-794-8557
Mailing Address - Fax:
Practice Address - Street 1:32114 1ST AVE S STE 200
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5760
Practice Address - Country:US
Practice Address - Phone:253-838-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE61089052122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist