Provider Demographics
NPI:1568140606
Name:SERWAN, MOHAMED
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:
Last Name:SERWAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 SUMMIT CREST WAY
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-5907
Mailing Address - Country:US
Mailing Address - Phone:347-909-6128
Mailing Address - Fax:
Practice Address - Street 1:23818 225TH AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-5088
Practice Address - Country:US
Practice Address - Phone:425-358-2553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE614092671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice