Healthcare Provider Details

I. General information

NPI: 1568381259
Provider Name (Legal Business Name): KIRAN MISTRY, DDS, P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 NE 179TH ST STE 108
RIDGEFIELD WA
98642-5758
US

IV. Provider business mailing address

12518 SE 24TH ST
VANCOUVER WA
98683-3825
US

V. Phone/Fax

Practice location:
  • Phone: 714-496-0682
  • Fax:
Mailing address:
  • Phone: 714-496-0682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateNULL

VIII. Authorized Official

Name: KIRAN MISTRY
Title or Position: OWNER
Credential: DDS
Phone: 714-496-0682