Provider Demographics
NPI:1477718229
Name:PEYSAKHOV, DMITRY (DMD)
Entity Type:Individual
Prefix:DR
First Name:DMITRY
Middle Name:
Last Name:PEYSAKHOV
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4047 258TH WAY SE
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-7763
Mailing Address - Country:US
Mailing Address - Phone:781-856-8080
Mailing Address - Fax:
Practice Address - Street 1:1416 HIGHLANDS DR NE
Practice Address - Street 2:SUITE 120
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-6240
Practice Address - Country:US
Practice Address - Phone:781-856-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0386441223S0112X
WADE 604986671223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery