Provider Demographics
NPI:1992146161
Name:SHOLUDKO, ANDREW PETER (DMD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:PETER
Last Name:SHOLUDKO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10830 19TH AVE SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-5181
Mailing Address - Country:US
Mailing Address - Phone:774-278-0412
Mailing Address - Fax:
Practice Address - Street 1:10830 19TH AVE SE
Practice Address - Street 2:SUITE A
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-5181
Practice Address - Country:US
Practice Address - Phone:774-278-0412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE604843871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADE6484387OtherWA DENTAL LICENSE
WAFS3990719OtherUNITED STATES DEPARTMENT OF JUSTICE DRUG ENFORCEMENT
CTFS3990719OtherUNITED STATES DEPARTMENT OF JUSTICE DRUG ENFORCEMENT ADMINISTRATION
CT010982OtherSTATE OF CT DEPARTMENT OF PUBLIC HEALTH