=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326194218
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREMONT FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4464 FREMONT AVE N SUITE 103
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98103-7273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-267-7300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4464 FREMONT AVE N SUITE 103
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98103-7273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIS
-----------------------------------------------------
Name | MAHVASH KHAJAVI-HARVEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 206-267-7300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 7667
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------