Provider Demographics
NPI:1497957617
Name:PERALTA, JORGE I (DDS)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:I
Last Name:PERALTA
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 1:15507 2ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-2540
Mailing Address - Country:US
Mailing Address - Phone:206-244-7800
Mailing Address - Fax:206-244-0566
Practice Address - Street 1:15507 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-2540
Practice Address - Country:US
Practice Address - Phone:206-244-7800
Practice Address - Fax:206-244-0566
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600028991223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics