Provider Demographics
NPI:1699830950
Name:GHAFGHAZI, SHAHRAM (DDS)
Entity Type:Individual
Prefix:MR
First Name:SHAHRAM
Middle Name:
Last Name:GHAFGHAZI
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 1:14257 AMBAUM BLVD SW # 201
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-1421
Mailing Address - Country:US
Mailing Address - Phone:617-605-5655
Mailing Address - Fax:
Practice Address - Street 1:14257 AMBAUM BLVD SW # 201
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-1421
Practice Address - Country:US
Practice Address - Phone:617-605-5655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000105181223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry