Healthcare Provider Details

I. General information

NPI: 1992474845
Provider Name (Legal Business Name): NILOUFAR DANESHPARVAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2021
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 S UNION AVE STE C27
TACOMA WA
98405-1334
US

IV. Provider business mailing address

2302 S UNION AVE STE C27
TACOMA WA
98405-1334
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDE61194327
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: