Provider Demographics
NPI:1144533142
Name:BAKHTIAR ARDI PRIBADI DDS PS
Entity type:Organization
Organization Name:BAKHTIAR ARDI PRIBADI DDS PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BAKHTIAR
Authorized Official - Middle Name:ARDI
Authorized Official - Last Name:PRIBADI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-474-9163
Mailing Address - Street 1:430 N WEST AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98223-1539
Mailing Address - Country:US
Mailing Address - Phone:360-474-9163
Mailing Address - Fax:360-474-9180
Practice Address - Street 1:430 N WEST AVE STE 1
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-1539
Practice Address - Country:US
Practice Address - Phone:360-474-9163
Practice Address - Fax:360-474-9180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-19
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010465261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental