Provider Demographics
NPI:1568741189
Name:KING, ISAAC WALTER (DDS)
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:WALTER
Last Name:KING
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 1:140 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-1040
Mailing Address - Country:US
Mailing Address - Phone:509-488-5256
Mailing Address - Fax:509-488-9939
Practice Address - Street 1:140 E MAIN ST
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1040
Practice Address - Country:US
Practice Address - Phone:509-488-5256
Practice Address - Fax:509-488-9939
Is Sole Proprietor?:No
Enumeration Date:2011-08-13
Last Update Date:2011-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60238949122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist