Provider Demographics
NPI:1043476989
Name:DELGADO, JAVIER DIEGO (LD)
Entity type:Individual
Prefix:
First Name:JAVIER
Middle Name:DIEGO
Last Name:DELGADO
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14400 AMBAUM BLVD SW STE Q
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-1447
Mailing Address - Country:US
Mailing Address - Phone:206-244-0956
Mailing Address - Fax:206-244-1017
Practice Address - Street 1:14400 AMBAUM BLVD SW STE Q
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-1447
Practice Address - Country:US
Practice Address - Phone:206-244-0956
Practice Address - Fax:206-244-1017
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5021050Medicaid