Healthcare Provider Details

I. General information

NPI: 1639458722
Provider Name (Legal Business Name): KARBAKHSCH PERIODONTICS & IMPLANTS - SOUTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2011
Last Update Date: 08/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 39TH AVE SW STE B
PUYALLUP WA
98373-3306
US

IV. Provider business mailing address

2302 S UNION AVE STE C22
TACOMA WA
98405-1334
US

V. Phone/Fax

Practice location:
  • Phone: 253-752-6336
  • Fax: 253-752-5655
Mailing address:
  • Phone: 253-752-6336
  • Fax: 253-752-5655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number8579
License Number StateWA

VIII. Authorized Official

Name: DR. MINOU KARBAKHSCH
Title or Position: OWNER
Credential: DDS, MSD
Phone: 253-752-6336