Provider Demographics
NPI:1598959413
Name:STAHL, GANNON BLAKE (DDS)
Entity Type:Individual
Prefix:DR
First Name:GANNON
Middle Name:BLAKE
Last Name:STAHL
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 1:14030 NE 24TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-3724
Mailing Address - Country:US
Mailing Address - Phone:425-641-3668
Mailing Address - Fax:425-747-7611
Practice Address - Street 1:14030 NE 24TH ST STE 100
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-3724
Practice Address - Country:US
Practice Address - Phone:425-641-3668
Practice Address - Fax:425-747-7611
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA10985122300000X
WADE000109851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist