Provider Demographics
NPI:1437746088
Name:GUSAK, PAVLO BOHDAN (DDS)
Entity type:Individual
Prefix:DR
First Name:PAVLO
Middle Name:BOHDAN
Last Name:GUSAK
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 1:2102 83RD AVE E
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98371-3747
Mailing Address - Country:US
Mailing Address - Phone:206-794-8557
Mailing Address - Fax:
Practice Address - Street 1:10221 198TH ST E STE A100
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:WA
Practice Address - Zip Code:98338-8038
Practice Address - Country:US
Practice Address - Phone:253-875-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2024-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE61089052122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist