Healthcare Provider Details

I. General information

NPI: 1932527314
Provider Name (Legal Business Name): REZAEE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 04/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 WILLAMETTE ST
EUGENE OR
97405-3131
US

IV. Provider business mailing address

2400 WILLAMETTE ST
EUGENE OR
97405-3131
US

V. Phone/Fax

Practice location:
  • Phone: 541-683-8034
  • Fax: 541-485-3134
Mailing address:
  • Phone: 541-683-8034
  • Fax: 541-485-3134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD7282
License Number StateOR

VIII. Authorized Official

Name: DR. SHAHRAM REZAEE
Title or Position: OWNER/DENTIST
Credential: DMD
Phone: 541-683-8034