Provider Demographics
NPI:1952556565
Name:JORGENSON, MICHAEL RYAN (DDS)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:RYAN
Last Name:JORGENSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 OLIVE WAY STE 1149
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1724
Mailing Address - Country:US
Mailing Address - Phone:206-682-3888
Mailing Address - Fax:206-382-1694
Practice Address - Street 1:509 OLIVE WAY STE 1149
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1724
Practice Address - Country:US
Practice Address - Phone:206-682-3888
Practice Address - Fax:206-682-1694
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010175122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist