Healthcare Provider Details

I. General information

NPI: 1356768774
Provider Name (Legal Business Name): NEAL C RAVAL DDS MSD PS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2014
Last Update Date: 03/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 112TH AVE NE SUITE 100
BELLEVUE WA
98004
US

IV. Provider business mailing address

1418 112TH AVE NE SUITE 100
BELLEVUE WA
98004
US

V. Phone/Fax

Practice location:
  • Phone: 425-453-1010
  • Fax: 425-637-8704
Mailing address:
  • Phone: 425-453-1010
  • Fax: 425-637-8704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDE60280931
License Number StateWA

VIII. Authorized Official

Name: MRS. JILL KLAIBER
Title or Position: OFFICE MANAGER
Credential:
Phone: 425-453-1010