Provider Demographics
NPI:1629498407
Name:MICHAEL A SACRO DDS PC
Entity Type:Organization
Organization Name:MICHAEL A SACRO DDS PC
Other - Org Name:FERNDALE FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:SACRO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-384-3440
Mailing Address - Street 1:6004 PORTAL WAY UNIT A
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-8382
Mailing Address - Country:US
Mailing Address - Phone:360-384-3440
Mailing Address - Fax:360-384-6028
Practice Address - Street 1:6004 PORTAL WAY UNIT A
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-8382
Practice Address - Country:US
Practice Address - Phone:360-384-3440
Practice Address - Fax:360-384-6028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60453211122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty