Provider Demographics
NPI:1538239728
Name:DERHALLI, MUNIB Y (DMD)
Entity type:Individual
Prefix:DR
First Name:MUNIB
Middle Name:Y
Last Name:DERHALLI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SE 120TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-4020
Mailing Address - Country:US
Mailing Address - Phone:360-254-8151
Mailing Address - Fax:360-254-7175
Practice Address - Street 1:300 SE 120TH AVE STE 500
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4020
Practice Address - Country:US
Practice Address - Phone:360-254-8151
Practice Address - Fax:360-254-7175
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE74321223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics