Provider Demographics
NPI:1164835872
Name:YAMAGUCHI, GORDON (DDS)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:YAMAGUCHI
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 1:108 22ND AVE SW STE 24
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-2871
Mailing Address - Country:US
Mailing Address - Phone:360-943-9480
Mailing Address - Fax:360-943-9568
Practice Address - Street 1:108 22ND AVE SW STE 24
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-2871
Practice Address - Country:US
Practice Address - Phone:360-943-9480
Practice Address - Fax:360-943-9568
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00004999122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist