Provider Demographics
NPI:1770983306
Name:BHARDWAJ, POOJA WALIA
Entity type:Individual
Prefix:
First Name:POOJA
Middle Name:WALIA
Last Name:BHARDWAJ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 984
Mailing Address - Street 2:
Mailing Address - City:DUVALL
Mailing Address - State:WA
Mailing Address - Zip Code:98019-0984
Mailing Address - Country:US
Mailing Address - Phone:253-951-2170
Mailing Address - Fax:
Practice Address - Street 1:15321 MAIN ST NE STE 321
Practice Address - Street 2:
Practice Address - City:DUVALL
Practice Address - State:WA
Practice Address - Zip Code:98019-8574
Practice Address - Country:US
Practice Address - Phone:425-318-6073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-02
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRES34811223G0001X
WADE606680341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH30.024395OtherOHIO DENTAL BOARD
WADE60668034OtherDENTAL LICENSE