Provider Demographics
NPI:1922097625
Name:GILL, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7501 W DESCHUTES PL
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7719
Mailing Address - Country:US
Mailing Address - Phone:509-783-1960
Mailing Address - Fax:509-783-7576
Practice Address - Street 1:7501 W DESCHUTES PL
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7719
Practice Address - Country:US
Practice Address - Phone:509-783-1960
Practice Address - Fax:509-783-7576
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE601475161223P0221X
WALD00002146231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8338410Medicare ID - Type Unspecified
WAQ51520Medicare ID - Type Unspecified
WAQ51520Medicare UPIN