MEDICARE: DR. IDIN ZHALEHDOUST SANI D.M.D.

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	122300000X	Dentist	059985	NY
2	1223P0221X	Pediatric Dentistry	DE60752640	WA

General Provider Information

NPI Number	:	1720447865
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IDIN ZHALEHDOUST SANI D.M.D.

Provider Business Mailing Address
First Line	:	18008 STATE ROUTE 410 E STE B
Second Line	:
City	:	BONNEY LAKE
State	:	WA
Zip	:	98391-7113
Country	:	US
Telephone Number	:	253-826-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	18008 STATE ROUTE 410 E STE B
Second Line	:
City	:	BONNEY LAKE
State	:	WA
Zip	:	98391-7113
Country	:	US
Telephone Number	:	253-826-5000
Fax Number	:

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

Provider Enumeration Date	:	02/17/2016
Last Update Date	:	07/24/2020

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