Basic Information
| Provider Information | |||||||||
| NPI: | 1760094668 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOMI | ||||||||
| FirstName: | PAVNEET | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3909 185TH PL SW | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980373813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063356770 | ||||||||
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| Practice Location | |||||||||
| Address1: | 732 SHAW RD STE B | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983725278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532677112 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2020 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DDS-09819 | IA | N | Dental Providers | Dentist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 122300000X | DE61126699 | WA | Y | Dental Providers | Dentist |
No ID Information.