Provider Demographics
NPI:1457421141
Name:ODEGARD, ROBERT LEON (DDS, MAGD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LEON
Last Name:ODEGARD
Suffix:
Gender:M
Credentials:DDS, MAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 DUVALL AVE NE
Mailing Address - Street 2:240
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98059-4675
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:451 DUVALL AVE NE
Practice Address - Street 2:SUITE 240
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98059-4675
Practice Address - Country:US
Practice Address - Phone:425-277-4000
Practice Address - Fax:425-226-2940
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000064331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice