Provider Demographics
NPI:1912907064
Name:GAGE, MICHAEL LAWRENCE (DDS PS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LAWRENCE
Last Name:GAGE
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 1:2520 N ALDER ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-6632
Mailing Address - Country:US
Mailing Address - Phone:253-759-5414
Mailing Address - Fax:253-756-6860
Practice Address - Street 1:2520 N ALDER ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-6632
Practice Address - Country:US
Practice Address - Phone:253-759-5414
Practice Address - Fax:253-756-6860
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA43441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
561035OtherUNITED CONCORDIA INS.
WA5383609Medicaid