Provider Demographics
NPI:1457774572
Name:SORENSEN, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:SORENSEN
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 1:1959 NE PACIFIC ST
Mailing Address - Street 2:BOX 357131
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-0001
Mailing Address - Country:US
Mailing Address - Phone:206-543-5297
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:BOX 357131
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-0001
Practice Address - Country:US
Practice Address - Phone:206-543-5297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-24
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADF60330315122300000X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist