Provider Demographics
NPI:1629591789
Name:DIBAJI, GHAZAL
Entity Type:Individual
Prefix:
First Name:GHAZAL
Middle Name:
Last Name:DIBAJI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 S 272ND ST APT D52
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-7973
Mailing Address - Country:US
Mailing Address - Phone:818-359-8912
Mailing Address - Fax:
Practice Address - Street 1:3602 6TH AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-5450
Practice Address - Country:US
Practice Address - Phone:253-777-4461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-20
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60740698122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist