Provider Demographics
NPI:1285884718
Name:SHAHRAM GHAFGHAZI DDS,PS
Entity type:Organization
Organization Name:SHAHRAM GHAFGHAZI DDS,PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAHRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GHAFGHAZI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-605-5655
Mailing Address - Street 1:14257 AMBAUM BLVD SW # 201
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-1421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14257 AMBAUM BLVD SW # 201
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-1421
Practice Address - Country:US
Practice Address - Phone:617-605-5655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-20
Last Update Date:2008-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000105181223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty