Provider Demographics
NPI:1639224660
Name:MERCHANT, FAHRA (DMD)
Entity Type:Individual
Prefix:
First Name:FAHRA
Middle Name:
Last Name:MERCHANT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14217 SE 83RD ST
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98059-3456
Mailing Address - Country:US
Mailing Address - Phone:253-584-8840
Mailing Address - Fax:
Practice Address - Street 1:10518 S TACOMA WAY STE B
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98499-5400
Practice Address - Country:US
Practice Address - Phone:253-584-8840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00009481122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5041355Medicaid