Provider Demographics
NPI:1891867883
Name:BURGESS, MOFFETT KABLE (DDS)
Entity Type:Individual
Prefix:MS
First Name:MOFFETT
Middle Name:KABLE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MS
Other - First Name:MOFFETT
Other - Middle Name:LEE
Other - Last Name:KABLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2211 2ND AVE W
Mailing Address - Street 2:COTTAGE HOUSE
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98119-2624
Mailing Address - Country:US
Mailing Address - Phone:206-852-0376
Mailing Address - Fax:
Practice Address - Street 1:4400 37TH AVE S
Practice Address - Street 2:DENTAL CLINIC
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-1609
Practice Address - Country:US
Practice Address - Phone:206-205-6003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00009652122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5044987Medicaid
WABB9787877OtherDEA