Provider Demographics
NPI:1134434475
Name:DEJBOD, NIMA (DMD)
Entity type:Individual
Prefix:DR
First Name:NIMA
Middle Name:
Last Name:DEJBOD
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 1:600 NW GILMAN BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2445
Mailing Address - Country:US
Mailing Address - Phone:425-786-1411
Mailing Address - Fax:
Practice Address - Street 1:600 NW GILMAN BLVD STE A
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2445
Practice Address - Country:US
Practice Address - Phone:425-786-1411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0380541223E0200X
WADE602338451223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics