Provider Demographics
NPI:1013123181
Name:MAHADEEP VIRK, DMD-PUYALLUP
Entity type:Organization
Organization Name:MAHADEEP VIRK, DMD-PUYALLUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHADEEP
Authorized Official - Middle Name:S
Authorized Official - Last Name:VIRK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:253-435-5656
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:253-435-5838
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:253-435-5838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty