Basic Information
| Provider Information | |||||||||
| NPI: | 1285051656 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DANIEL PECK DDS INC PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20855 BOND RD NE | ||||||||
| Address2: | |||||||||
| City: | POULSBO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983709014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607795546 | ||||||||
| FaxNumber: | 3606974951 | ||||||||
| Practice Location | |||||||||
| Address1: | 20855 BOND RD NE | ||||||||
| Address2: | |||||||||
| City: | POULSBO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983709014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607795546 | ||||||||
| FaxNumber: | 3606974951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2014 | ||||||||
| LastUpdateDate: | 10/08/2015 | ||||||||
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| AuthorizedOfficialLastName: | PECK | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER / PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3607795546 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 10941 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.