Provider Demographics
NPI:1477548766
Name:PAWLAK, DEREK T (LD)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:T
Last Name:PAWLAK
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 BAY LYN DR
Mailing Address - Street 2:
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264-9404
Mailing Address - Country:US
Mailing Address - Phone:360-318-0880
Mailing Address - Fax:360-318-0880
Practice Address - Street 1:161 BAY LYN DR
Practice Address - Street 2:
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264-9404
Practice Address - Country:US
Practice Address - Phone:360-318-0880
Practice Address - Fax:360-318-0880
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025108DN00000270122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA025108DN00000270OtherDEPT OF HEALTH
WA5036017Medicaid