MEDICARE: DR. ROOZBEH KHOSRAVI DMD, PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DE60504324	WA

General Provider Information

NPI Number	:	1629433891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROOZBEH KHOSRAVI DMD, PHD

Provider Business Mailing Address
First Line	:	22620 SE 4TH ST STE 210
Second Line	:
City	:	SAMMAMISH
State	:	WA
Zip	:	98074-7375
Country	:	US
Telephone Number	:	425-526-2060
Fax Number	:

Provider Business Practice Location Address
First Line	:	22620 SE 4TH ST STE 210
Second Line	:
City	:	SAMMAMISH
State	:	WA
Zip	:	98074-7375
Country	:	US
Telephone Number	:	425-526-2060
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2015
Last Update Date	:	07/21/2022

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