Provider Demographics
NPI:1407191265
Name:ISSAQUAH VALLEY DENTAL CARE
Entity Type:Organization
Organization Name:ISSAQUAH VALLEY DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:DHANKHAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-392-4122
Mailing Address - Street 1:1660 NW GILMAN BLVD
Mailing Address - Street 2:SUITE C1
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-5340
Mailing Address - Country:US
Mailing Address - Phone:425-392-4122
Mailing Address - Fax:425-392-1167
Practice Address - Street 1:1660 NW GILMAN BLVD
Practice Address - Street 2:SUITE C1
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-5340
Practice Address - Country:US
Practice Address - Phone:425-392-4122
Practice Address - Fax:425-392-1167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000098381223G0001X
WADE000095091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty