Provider Demographics
NPI:1871867069
Name:JETHWANI, MONICA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MONICA
Middle Name:
Last Name:JETHWANI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 STONE WAY N APT 424
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-8044
Mailing Address - Country:US
Mailing Address - Phone:310-447-8684
Mailing Address - Fax:
Practice Address - Street 1:601 S CARR RD STE 350
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5854
Practice Address - Country:US
Practice Address - Phone:425-227-3368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-06
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014134881223G0001X
WADE606650491223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAPENDINGMedicaid