Provider Demographics
NPI:1265815682
Name:FAZELI, AFSOON (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:AFSOON
Middle Name:
Last Name:FAZELI
Suffix:
Gender:F
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 NE 189TH PL
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98155-2744
Mailing Address - Country:US
Mailing Address - Phone:206-218-2010
Mailing Address - Fax:
Practice Address - Street 1:669 WOODLAND SQUARE LOOP SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1038
Practice Address - Country:US
Practice Address - Phone:360-359-4840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-02
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60565542122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist