Healthcare Provider Details

I. General information

NPI: 1972378842
Provider Name (Legal Business Name): KEYVAN DASTKHOSH NIKGHALB I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16521 13TH AVE W STE 101
LYNNWOOD WA
98037-8530
US

IV. Provider business mailing address

707 PARNASSUS AVE
SAN FRANCISCO CA
94143-2210
US

V. Phone/Fax

Practice location:
  • Phone: 425-743-3054
  • Fax:
Mailing address:
  • Phone: 206-999-6673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number70094939
License Number StateWA
# 2
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: