Provider Demographics
NPI:1427138064
Name:PRIBADI, BAKHTIAR ARDI (DDS)
Entity type:Individual
Prefix:DR
First Name:BAKHTIAR
Middle Name:ARDI
Last Name:PRIBADI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11809 63RD AVE SE
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98296-6956
Mailing Address - Country:US
Mailing Address - Phone:415-601-0095
Mailing Address - Fax:
Practice Address - Street 1:430 N WEST AVE STE 1
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-1539
Practice Address - Country:US
Practice Address - Phone:360-474-9163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010465122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist