Provider Demographics
NPI:1104849900
Name:DERAKSHANI, KAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:KAM
Middle Name:
Last Name:DERAKSHANI
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 1:1551 116TH AVE NE STE B1
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3814
Mailing Address - Country:US
Mailing Address - Phone:425-373-1605
Mailing Address - Fax:
Practice Address - Street 1:1551 116TH AVE. NE
Practice Address - Street 2:#B-1
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004
Practice Address - Country:US
Practice Address - Phone:425-373-1605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE77121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5028782Medicare ID - Type Unspecified