Individual
EBRAHIM MIRJALILI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
2120 RYAN RD, BUCKLEY, WA 98321
(360) 829-4920
Mailing address
PO BOX 34703, SEATTLE, WA 98124-1703
(206) 764-0112
(206) 764-0489
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
DE00007824
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0175785
STATE LABOR & INDUSTRIES
WA
05
—
5025234
—
WA
01
—
MI9110
REGENCE BLUE SHIELD
WA
Enumeration date
11/01/2006
Last updated
07/30/2018
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