Provider Demographics
NPI:1619037157
Name:FAIRWOOD ORTHODONTICS
Entity Type:Organization
Organization Name:FAIRWOOD ORTHODONTICS
Other - Org Name:MERCER ISLAND ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORTHODONTIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHORAK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:425-235-8800
Mailing Address - Street 1:14300 SE PETROVITSKY ROAD
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058
Mailing Address - Country:US
Mailing Address - Phone:425-235-8800
Mailing Address - Fax:425-235-0288
Practice Address - Street 1:14300 SE PETROVITSKY ROAD
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058
Practice Address - Country:US
Practice Address - Phone:425-235-8800
Practice Address - Fax:425-235-0288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000089571223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty