Provider Demographics
NPI:1720447865
Name:ZHALEHDOUST SANI, IDIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:IDIN
Middle Name:
Last Name:ZHALEHDOUST SANI
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 1:18008 STATE ROUTE 410 E STE B
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-7113
Mailing Address - Country:US
Mailing Address - Phone:253-826-5000
Mailing Address - Fax:
Practice Address - Street 1:18008 STATE ROUTE 410 E STE B
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-7113
Practice Address - Country:US
Practice Address - Phone:253-826-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-17
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059985122300000X
WADE607526401223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist