Provider Demographics
NPI:1700164969
Name:FAKHRAVAR, BEHNAM (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:BEHNAM
Middle Name:
Last Name:FAKHRAVAR
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 SE 192ND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9679
Mailing Address - Country:US
Mailing Address - Phone:360-219-9587
Mailing Address - Fax:
Practice Address - Street 1:322 SE 192ND AVE STE 100
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-9679
Practice Address - Country:US
Practice Address - Phone:219-360-9587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-21
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS618871223P0300X
WI10017791223P0300X
TX285731223P0300X
ORD95651223P0300X
WADE602316861223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty