Provider Demographics
NPI:1912485061
Name:FERGUSON, BRIAN KANJI (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KANJI
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11400 OLYMPUS WAY APT P101
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98332-8796
Mailing Address - Country:US
Mailing Address - Phone:562-676-6147
Mailing Address - Fax:
Practice Address - Street 1:11065 PACIFIC CREST PL NW STE B105
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-6607
Practice Address - Country:US
Practice Address - Phone:360-261-6154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60862722122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist