Provider Demographics
NPI:1770293284
Name:TETERUD, DAKOTA LAYNE
Entity type:Individual
Prefix:
First Name:DAKOTA
Middle Name:LAYNE
Last Name:TETERUD
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 1:201 BROADWAY E
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-5723
Mailing Address - Country:US
Mailing Address - Phone:509-398-3067
Mailing Address - Fax:
Practice Address - Street 1:201 BROADWAY E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-5723
Practice Address - Country:US
Practice Address - Phone:509-398-3067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-25
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA60858019183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician