Provider Demographics
NPI:1609578418
Name:KAST, MICHAEL BRIAN (LD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRIAN
Last Name:KAST
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 1:228 W 1ST ST STE X
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-2639
Mailing Address - Country:US
Mailing Address - Phone:360-477-4768
Mailing Address - Fax:
Practice Address - Street 1:228 W 1ST ST STE X
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-2639
Practice Address - Country:US
Practice Address - Phone:360-477-4768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD0000X, 292200000X
WADN60939854122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No292200000XLaboratoriesDental Laboratory