Healthcare Provider Details

I. General information

NPI: 1013895598
Provider Name (Legal Business Name): MEVADEE PIBULNIYOM
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2025
Last Update Date: 08/23/2025
Certification Date: 08/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 MAIN ST STE 107
TACOMA WA
98407-3177
US

IV. Provider business mailing address

5005 MAIN ST STE 107
TACOMA WA
98407-3177
US

V. Phone/Fax

Practice location:
  • Phone: 253-262-0024
  • Fax:
Mailing address:
  • Phone: 253-262-0024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number61668744
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: