Provider Demographics
NPI:1003237538
Name:A NEW IMAGE DENTURE CLINIC
Entity Type:Organization
Organization Name:A NEW IMAGE DENTURE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTURIST
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:NABEGH
Authorized Official - Last Name:GHATTAS
Authorized Official - Suffix:
Authorized Official - Credentials:DPD
Authorized Official - Phone:253-770-7707
Mailing Address - Street 1:2811 E MAIN
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3167
Mailing Address - Country:US
Mailing Address - Phone:253-770-7707
Mailing Address - Fax:253-770-8784
Practice Address - Street 1:2811 E MAIN
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3167
Practice Address - Country:US
Practice Address - Phone:253-770-7707
Practice Address - Fax:253-770-8784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000199122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5027412Medicaid