Provider Demographics
NPI:1669872180
Name:MORALES, L. CARLOS (DDS, PS)
Entity type:Individual
Prefix:
First Name:L. CARLOS
Middle Name:
Last Name:MORALES
Suffix:
Gender:M
Credentials:DDS, PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23925 225TH WAY SE STE A
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-5233
Mailing Address - Country:US
Mailing Address - Phone:425-432-0561
Mailing Address - Fax:425-432-2938
Practice Address - Street 1:23925 225TH WAY SE STE A
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-5233
Practice Address - Country:US
Practice Address - Phone:425-432-0561
Practice Address - Fax:425-432-2938
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 00007645122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA911921134OtherTAX ID NUMBER