1639458722 NPI number — KARBAKHSCH PERIODONTICS & IMPLANTS - SOUTH PLLC

Table of content: (NPI 1639458722)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639458722 NPI number — KARBAKHSCH PERIODONTICS & IMPLANTS - SOUTH PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KARBAKHSCH PERIODONTICS & IMPLANTS - SOUTH PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639458722
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2302 S UNION AVE STE C22
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98405-1334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-752-6336
Provider Business Mailing Address Fax Number:
253-752-5655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
819 39TH AVE SW STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98373-3306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-752-6336
Provider Business Practice Location Address Fax Number:
253-752-5655
Provider Enumeration Date:
08/08/2011

Additional Information

Authorized Official

Authorized Official Last Name:
KARBAKHSCH
Authorized Official First Name:
MINOU
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
253-752-6336

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X , with the licence number:  8579 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8579 . This is a "WASHINGTON STATE DENTAL LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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