Provider Demographics
NPI:1730309113
Name:VIRK, MAHADEEP SINGH (DMD)
Entity Type:Individual
Prefix:
First Name:MAHADEEP
Middle Name:SINGH
Last Name:VIRK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10317 122ND ST E
Mailing Address - Street 2:SUITE D
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-2632
Mailing Address - Country:US
Mailing Address - Phone:253-435-5656
Mailing Address - Fax:
Practice Address - Street 1:10317 122ND ST E
Practice Address - Street 2:SUITE D
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-2632
Practice Address - Country:US
Practice Address - Phone:253-435-5656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE81441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice