Provider Demographics
NPI:1396800025
Name:RISKEDAHL, DEAN (OD)
Entity type:Individual
Prefix:DR
First Name:DEAN
Middle Name:
Last Name:RISKEDAHL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5202
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98064-5202
Mailing Address - Country:US
Mailing Address - Phone:253-520-0158
Mailing Address - Fax:253-854-9860
Practice Address - Street 1:2092 32ND AVE NE
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-7349
Practice Address - Country:US
Practice Address - Phone:253-520-0158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001900152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2022929Medicaid
WA474099001OtherGROUP HEALTH
WAU23786Medicare UPIN
WAGAB09328Medicare ID - Type Unspecified
WA2022929Medicaid
WA6198350001Medicare NSC