Provider Demographics
NPI:1508314097
Name:GENTLE ENDODONTICS OF KENT
Entity Type:Organization
Organization Name:GENTLE ENDODONTICS OF KENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VAHID
Authorized Official - Middle Name:
Authorized Official - Last Name:ATABAKHSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-852-1332
Mailing Address - Street 1:24401 104TH AVE SE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-4903
Mailing Address - Country:US
Mailing Address - Phone:253-850-6999
Mailing Address - Fax:
Practice Address - Street 1:24401 104TH AVE SE
Practice Address - Street 2:SUITE 202
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-4903
Practice Address - Country:US
Practice Address - Phone:253-850-6999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60103522122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1710049119OtherENDODONTIST
WA1104292887OtherENDODONTIST