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General NPI Number Information
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NPI Number | 1003237538
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Entity Type | Organization
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Legal Business Name | A NEW IMAGE DENTURE CLINIC
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Dates
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Enumeration Date | 12/31/2013
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Last Update Date | 12/31/2013
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Provider Practice Location Address
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Address Line | 2811 E MAIN
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City | PUYALLUP
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State | WA
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Zip | 98372-3167
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Country | US
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Telephone | 253-770-7707
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Fax | 253-770-8784
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Provider Business Mailing Address
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Address Line | 2811 E MAIN
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City | PUYALLUP
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State | WA
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Zip | 98372-3167
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Country | US
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Telephone | 253-770-7707
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Fax | 253-770-8784
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Authorized Official
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Title or Position | DENTURIST
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Name | MR. PETER NABEGH GHATTAS
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Credential | D.P.D.
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Telephone | 253-770-7707
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122400000X
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Taxonomy Name | Denturist
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License Number | DN00000199
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License Number State | WA
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