Provider Demographics
NPI:1942533351
Name:KENT NUTTALL DMD PS
Entity Type:Organization
Organization Name:KENT NUTTALL DMD PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLECCHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-939-0700
Mailing Address - Street 1:722 12TH ST SE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-6708
Mailing Address - Country:US
Mailing Address - Phone:253-939-0700
Mailing Address - Fax:
Practice Address - Street 1:722 12TH ST SE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-6708
Practice Address - Country:US
Practice Address - Phone:253-939-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA74391223G0001X
WA108821223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty