Provider Demographics
NPI:1710210315
Name:FERGUSON, KONRAD DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:KONRAD
Middle Name:DAVID
Last Name:FERGUSON
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:BLDG 9900, 2ND FLOOR
Mailing Address - Street 2:U.S. ARMY DENTAL ACTIVITY - FORT LEWIS
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-1100
Mailing Address - Country:US
Mailing Address - Phone:253-968-4039
Mailing Address - Fax:253-968-5919
Practice Address - Street 1:BLDG 9900, 2ND FLOOR
Practice Address - Street 2:U.S. ARMY DENTAL ACTIVITY - FORT LEWIS
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-1100
Practice Address - Country:US
Practice Address - Phone:253-968-4039
Practice Address - Fax:253-968-5919
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE601128581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice