Provider Demographics
NPI:1689068769
Name:KHACHATRYAN, TIGRAN
Entity Type:Individual
Prefix:
First Name:TIGRAN
Middle Name:
Last Name:KHACHATRYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15446 BEL RED RD STE 400
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-5505
Mailing Address - Country:US
Mailing Address - Phone:425-558-9998
Mailing Address - Fax:
Practice Address - Street 1:15446 BEL RED RD STE 400
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-5505
Practice Address - Country:US
Practice Address - Phone:425-558-9998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010655122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA208094457OtherTIN