Healthcare Provider Details

I. General information

NPI: 1508493388
Provider Name (Legal Business Name): TOMOMI J IDA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 SE EVERETT MALL WAY
EVERETT WA
98208-3208
US

IV. Provider business mailing address

4111 194TH ST SW
LYNNWOOD WA
98036-4604
US

V. Phone/Fax

Practice location:
  • Phone: 425-341-7827
  • Fax:
Mailing address:
  • Phone: 425-835-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE61165856
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDE61165856
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: