Active NPI
Clark Kenneth Kvistad, D.D.S.
- Periodontics
- Edmonds, WA
National Provider Identifier
1093948267
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Periodontics
- License
- 3580
- Practice address
- 21807 76TH Ave W
Edmonds, WA 98026-7938 - Phone
- (425) 775-2002
- NPI assigned
- Sep 3, 2009
- Last updated
- Sep 3, 2009
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Periodontics | 1223P0300X | 3580 | WA | Primary |
Addresses
Primary practice location
21807 76TH Ave W
Edmonds, WA 98026-7938
Mailing address
21807 76TH Ave W
Edmonds, WA 98026-7938
Phone (425) 775-2002
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 3580 | WA | MD | Periodontist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Song Periodontics and Dental Implants PLLC | Periodontics | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
dba Pacific Northwest Oral Medicine
- Periodontics
- Tukwila, WA
- NPI 1386202539
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1251936000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1251936000000",
"number": "1093948267",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "21807 76TH AVE W",
"city": "EDMONDS",
"state": "WA",
"postal_code": "980267938",
"telephone_number": "425-775-2002"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "21807 76TH AVE W",
"city": "EDMONDS",
"state": "WA",
"postal_code": "980267938",
"telephone_number": "425-775-2002"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KVISTAD",
"first_name": "CLARK",
"middle_name": "KENNETH",
"name_prefix": "Dr.",
"credential": "D.D.S.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2009-09-03",
"last_updated": "2009-09-03",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0300X",
"taxonomy_group": "",
"desc": "Dentist, Periodontics",
"state": "WA",
"license": "3580",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Edmonds, WA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 3, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.