Healthcare Provider Details

I. General information

NPI: 1114830668
Provider Name (Legal Business Name): SKYKOMISH DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 E STEVENS AVE STE A
SULTAN WA
98294
US

IV. Provider business mailing address

6816 NE 153RD PL APT D
KENMORE WA
98028-4927
US

V. Phone/Fax

Practice location:
  • Phone: 702-954-9777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MOHAMMAD N SHARIFI
Title or Position: GENERAL DENTIST
Credential: DMD
Phone: 702-954-9777