Basic Information
| Provider Information | |||||||||
| NPI: | 1215007208 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAR | ||||||||
| FirstName: | HAYDON | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3835 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981243835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065483114 | ||||||||
| FaxNumber: | 2067626355 | ||||||||
| Practice Location | |||||||||
| Address1: | 6020 35TH AVE SW | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981263002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064616966 | ||||||||
| FaxNumber: | 2064616968 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 11/11/2016 | ||||||||
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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 | DE00006374 | WA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 5014675 | 05 | WA | MEDICAID |