Healthcare Provider Details

I. General information

NPI: 1083148308
Provider Name (Legal Business Name): NORTHWEST MAXILLOFACIAL AND COSMETIC SURGERY ASSOCIATES PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6505 226TH PL SE STE 100
ISSAQUAH WA
98027-8905
US

IV. Provider business mailing address

6505 226TH PL SE STE 100
ISSAQUAH WA
98027-8905
US

V. Phone/Fax

Practice location:
  • Phone: 425-332-5333
  • Fax: 425-332-5332
Mailing address:
  • Phone: 425-332-5333
  • Fax: 425-332-5332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberMD60383921
License Number StateWA

VIII. Authorized Official

Name: DR. HARDEEP S DHALIWAL
Title or Position: OWNER / SURGEON
Credential: DMD, MD
Phone: 425-332-5333