Provider Demographics
NPI:1629433891
Name:KHOSRAVI, ROOZBEH (DMD, PHD)
Entity Type:Individual
Prefix:DR
First Name:ROOZBEH
Middle Name:
Last Name:KHOSRAVI
Suffix:
Gender:M
Credentials:DMD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22620 SE 4TH ST STE 210
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98074-7375
Mailing Address - Country:US
Mailing Address - Phone:425-526-2060
Mailing Address - Fax:
Practice Address - Street 1:22620 SE 4TH ST STE 210
Practice Address - Street 2:
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98074-7375
Practice Address - Country:US
Practice Address - Phone:425-526-2060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE605043241223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics