Provider Demographics
NPI:1578676540
Name:KRELL, RICKY ROBERT (DDS)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:ROBERT
Last Name:KRELL
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 1:6108 1/2 MOTOR AVE SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-1529
Mailing Address - Country:US
Mailing Address - Phone:253-588-5228
Mailing Address - Fax:253-582-5142
Practice Address - Street 1:6108 1/2 MOTOR AVE SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-1529
Practice Address - Country:US
Practice Address - Phone:253-588-5228
Practice Address - Fax:253-582-5142
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA50841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice