Provider Demographics
NPI:1245320605
Name:CHAVES, RUTILLO O JR (DDS)
Entity type:Individual
Prefix:DR
First Name:RUTILLO
Middle Name:O
Last Name:CHAVES
Suffix:JR
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 1:7631 212TH ST SW
Mailing Address - Street 2:SUITE 101-A
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7565
Mailing Address - Country:US
Mailing Address - Phone:425-280-7792
Mailing Address - Fax:425-742-4073
Practice Address - Street 1:7631 212TH ST SW
Practice Address - Street 2:SUITE 101-A
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7565
Practice Address - Country:US
Practice Address - Phone:425-280-7792
Practice Address - Fax:425-742-4073
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA62001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA56200OtherWASHINGTON DENTAL SERVICE