Provider Demographics
NPI:1326194218
Name:FREMONT FAMILY DENTISTRY
Entity Type:Organization
Organization Name:FREMONT FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIS
Authorized Official - Prefix:
Authorized Official - First Name:MAHVASH
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAJAVI-HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-267-7300
Mailing Address - Street 1:4464 FREMONT AVE N
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-7273
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4464 FREMONT AVE N
Practice Address - Street 2:SUITE 103
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-7273
Practice Address - Country:US
Practice Address - Phone:206-267-7300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA76671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty