Provider Demographics
NPI:1679650576
Name:MIRJALILI, EBRAHIM (DDS)
Entity Type:Individual
Prefix:
First Name:EBRAHIM
Middle Name:
Last Name:MIRJALILI
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:PO BOX 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:206-764-0112
Mailing Address - Fax:206-764-0489
Practice Address - Street 1:2120 RYAN RD
Practice Address - Street 2:
Practice Address - City:BUCKLEY
Practice Address - State:WA
Practice Address - Zip Code:98321
Practice Address - Country:US
Practice Address - Phone:360-829-4920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000078241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5025234Medicaid
WA0175785OtherSTATE LABOR & INDUSTRIES
WAMI9110OtherREGENCE BLUE SHIELD