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General NPI Number Information
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NPI Number | 1174883169
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Entity Type | Organization
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Legal Business Name | DO, GHORBANIAN, IM, KWON
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Dates
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Enumeration Date | 05/23/2012
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Last Update Date | 05/23/2012
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Provider Practice Location Address
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Address Line | 33600 6TH AVE SO SUITE - 102
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City | FEDERAL WAY
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State | WA
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Zip | 98003
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Country | US
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Telephone | 253-838-3232
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Fax | 253-838-6063
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Provider Business Mailing Address
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Address Line | 33600 6TH AVE SO SUITE - 102
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City | FEDERAL WAY
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State | WA
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Zip | 98003
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Country | US
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Telephone | 253-838-3232
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Fax | 253-838-6063
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Authorized Official
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Title or Position | DENTIST / OWNER
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Name | MRS. CHAU THI DO
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Credential | DMD
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Telephone | 253-838-3232
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DE00010883
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | DE00009746
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License Number State | WA
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DE00010309
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License Number State | WA
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