Healthcare Provider Details

I. General information

NPI: 1235791427
Provider Name (Legal Business Name): ICHS MOBILE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 8TH AVE S
SEATTLE WA
98104-3032
US

IV. Provider business mailing address

PO BOX 3007
SEATTLE WA
98114-3007
US

V. Phone/Fax

Practice location:
  • Phone: 206-445-8454
  • Fax:
Mailing address:
  • Phone: 206-788-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: HERMES SHAHBAZIAN
Title or Position: CFO
Credential:
Phone: 206-788-3618