Provider Demographics
NPI:1356596811
Name:AA BANSAL PLLC
Entity type:Organization
Organization Name:AA BANSAL PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHRADHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BANSAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-830-4773
Mailing Address - Street 1:615 WINDSOR DR SE
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98074-3422
Mailing Address - Country:US
Mailing Address - Phone:253-326-7777
Mailing Address - Fax:866-528-2025
Practice Address - Street 1:317 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4234
Practice Address - Country:US
Practice Address - Phone:253-326-7777
Practice Address - Fax:866-528-2025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-25
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6028402441223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5058490Medicaid