=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083148308
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWEST MAXILLOFACIAL AND COSMETIC SURGERY ASSOCIATES PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2017
-----------------------------------------------------
Last Update Date | 04/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6505 226TH PL SE STE 100
-----------------------------------------------------
City | ISSAQUAH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98027-8905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-332-5333
-----------------------------------------------------
Fax | 425-332-5332
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6505 226TH PL SE STE 100
-----------------------------------------------------
City | ISSAQUAH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98027-8905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-332-5333
-----------------------------------------------------
Fax | 425-332-5332
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / SURGEON
-----------------------------------------------------
Name | DR. HARDEEP S DHALIWAL
-----------------------------------------------------
Credential | DMD, MD
-----------------------------------------------------
Telephone | 425-332-5333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | MD60383921
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------