Basic Information
| Provider Information | |||||||||
| NPI: | 1225119944 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOUDARZI | ||||||||
| FirstName: | ABRAH | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4111 194TH ST SW | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258355204 | ||||||||
| FaxNumber: | 4258355205 | ||||||||
| Practice Location | |||||||||
| Address1: | 4111 194TH ST SW | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258355204 | ||||||||
| FaxNumber: | 4258355205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DE00006151 | WA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 5004486 | 05 | WA | MEDICAID |