Provider Demographics
NPI:1962913509
Name:ROOZBEH KHOSRAVI DMD PHD LLC
Entity type:Organization
Organization Name:ROOZBEH KHOSRAVI DMD PHD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROOZBEH
Authorized Official - Middle Name:
Authorized Official - Last Name:KHOSRAVI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD PHD MSD
Authorized Official - Phone:617-466-9090
Mailing Address - Street 1:22620 SE 4TH ST STE 210
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98074-7375
Mailing Address - Country:US
Mailing Address - Phone:425-526-2060
Mailing Address - Fax:
Practice Address - Street 1:22620 SE 4TH ST STE 210
Practice Address - Street 2:
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98074-7375
Practice Address - Country:US
Practice Address - Phone:425-526-2060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1629433891Medicaid