Provider Demographics
NPI:1467646497
Name:SIDHU, PRABHJOT S (DDS)
Entity Type:Individual
Prefix:DR
First Name:PRABHJOT
Middle Name:S
Last Name:SIDHU
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 1:3870 82ND AVE SE
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-3539
Mailing Address - Country:US
Mailing Address - Phone:347-453-2111
Mailing Address - Fax:
Practice Address - Street 1:18910 28TH AVE W STE 202
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4701
Practice Address - Country:US
Practice Address - Phone:425-775-5557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE-00010707122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist