Provider Demographics
NPI:1639458722
Name:KARBAKHSCH PERIODONTICS & IMPLANTS - SOUTH PLLC
Entity Type:Organization
Organization Name:KARBAKHSCH PERIODONTICS & IMPLANTS - SOUTH PLLC
Other - Org Name:MK PERIODONTICS & IMPLANTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MINOU
Authorized Official - Middle Name:
Authorized Official - Last Name:KARBAKHSCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:253-752-6336
Mailing Address - Street 1:2302 S UNION AVE STE C22
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1334
Mailing Address - Country:US
Mailing Address - Phone:253-752-6336
Mailing Address - Fax:253-752-5655
Practice Address - Street 1:819 39TH AVE SW STE B
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3306
Practice Address - Country:US
Practice Address - Phone:253-752-6336
Practice Address - Fax:253-752-5655
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KARBAKHSCH PERIODONTICS & IMPLANTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA85791223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8579OtherWASHINGTON STATE DENTAL LICENSE