Provider Demographics
NPI:1578884946
Name:SHIYAB, TARIQ M (DDS)
Entity Type:Individual
Prefix:
First Name:TARIQ
Middle Name:M
Last Name:SHIYAB
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 1:325 CANYON DR APT 8
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-1074
Mailing Address - Country:US
Mailing Address - Phone:443-851-6017
Mailing Address - Fax:509-882-1153
Practice Address - Street 1:1000 WALLACE WAY
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:WA
Practice Address - Zip Code:98930-8805
Practice Address - Country:US
Practice Address - Phone:509-882-4491
Practice Address - Fax:509-882-1153
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60161577122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist