Basic Information
| Provider Information | |||||||||
| NPI: | 1124198106 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BECK | ||||||||
| FirstName: | WENDELL | ||||||||
| MiddleName: | GENE | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 905 SPRUCE ST | ||||||||
| Address2: | STE. 300 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981042474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064616935 | ||||||||
| FaxNumber: | 2064618382 | ||||||||
| Practice Location | |||||||||
| Address1: | 9245 RAINIER AVE S | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981185569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064616981 | ||||||||
| FaxNumber: | 2064618581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 09/12/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DE00009287 | WA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 5042015 | 05 | WA | MEDICAID |