Provider Demographics
NPI:1477536027
Name:SEBASTIAN, MARK J (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:SEBASTIAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33516 9TH AVE S
Mailing Address - Street 2:WESTHILL COURT BLDG 2
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6322
Mailing Address - Country:US
Mailing Address - Phone:253-941-6242
Mailing Address - Fax:253-952-2129
Practice Address - Street 1:33516 9TH AVE S
Practice Address - Street 2:WESTHILL COURT BLDG 2
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6322
Practice Address - Country:US
Practice Address - Phone:253-941-6242
Practice Address - Fax:253-952-2129
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA5374122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0040673OtherLABOR & INDUSTRIES