Healthcare Provider Details

I. General information

NPI: 1366019820
Provider Name (Legal Business Name): PANTEA NAZEMAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2021
Last Update Date: 06/22/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 S RENTON VILLAGE PL STE 610
RENTON WA
98057-3287
US

IV. Provider business mailing address

10401 113TH PL NE
KIRKLAND WA
98033-5082
US

V. Phone/Fax

Practice location:
  • Phone: 425-271-5812
  • Fax:
Mailing address:
  • Phone: 408-966-5485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDE61150281
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: