Basic Information
| Provider Information | |||||||||
| NPI: | 1679633184 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLESPIE | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13200 SE MCGILLIVRAY BLVD | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986837040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608926132 | ||||||||
| FaxNumber: | 3608920297 | ||||||||
| Practice Location | |||||||||
| Address1: | 13200 SE MCGILLIVRAY BLVD | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986837040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608926132 | ||||||||
| FaxNumber: | 3608920297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 09/10/2010 | ||||||||
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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 | 122300000X | 5353 | WA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 5557301 | 01 | WA | DSHS | OTHER |