Provider Demographics
NPI:1740588995
Name:GRIFFIN, AUTUMN JOY
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:JOY
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7255 115TH PL SE
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98056-4302
Mailing Address - Country:US
Mailing Address - Phone:603-339-2934
Mailing Address - Fax:
Practice Address - Street 1:12911 120TH AVE NE # 10
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3027
Practice Address - Country:US
Practice Address - Phone:425-821-9833
Practice Address - Fax:425-821-9443
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-10
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WADE60303059122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program