Healthcare Provider Details

I. General information

NPI: 1679918528
Provider Name (Legal Business Name): NURANI, MITCHELL, KIM, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2013
Last Update Date: 12/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 STATE ROUTE 9 NE
LAKE STEVENS WA
98258
US

IV. Provider business mailing address

709 STATE ROUTE 9 NE
LAKE STEVENS WA
98258
US

V. Phone/Fax

Practice location:
  • Phone: 425-249-4129
  • Fax: 425-334-8475
Mailing address:
  • Phone: 425-249-4129
  • Fax: 425-334-8475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE00008078
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ASHIFA A NURANI
Title or Position: PRESIDENT
Credential: DDS
Phone: 714-578-6358