# EBRAHIM MIRJALILI

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** No

## Provider details

- **NPI number:** 1679650576
- **Gender:** Man
- **Credential:** DDS

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | DE00007824 | WA | Yes |

## Other

- **Enumeration date:** 11/01/2006
- **Last updated:** 07/30/2018

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 0175785 | STATE LABOR & INDUSTRIES | WA |
| 05 | — | 5025234 | — | WA |
| 01 | — | MI9110 | REGENCE BLUE SHIELD | WA |