Provider Demographics
NPI:1649792706
Name:KANACK, TREVOR DYLAN (DDS)
Entity type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:DYLAN
Last Name:KANACK
Suffix:
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 1:820 BLANCHARD ST UNIT 1501
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98121-2656
Mailing Address - Country:US
Mailing Address - Phone:469-369-6671
Mailing Address - Fax:
Practice Address - Street 1:220 BROADWAY E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-5724
Practice Address - Country:US
Practice Address - Phone:206-686-3828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-11
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33233122300000X
WADE608395531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist