Healthcare Provider Details

I. General information

NPI: 1780090357
Provider Name (Legal Business Name): ABDELRAHIM ELJACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2014
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 WALLACE WAY
GRANDVIEW WA
98930-8805
US

IV. Provider business mailing address

1000 WALLACE WAY
GRANDVIEW WA
98930-8805
US

V. Phone/Fax

Practice location:
  • Phone: 509-882-3444
  • Fax: 509-882-1097
Mailing address:
  • Phone: 509-882-3444
  • Fax: 509-882-1097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60882177
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: