Healthcare Provider Details

I. General information

NPI: 1942980537
Provider Name (Legal Business Name): MS. MONA GHIAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date: 02/21/2024
Reactivation Date: 07/24/2025

III. Provider practice location address

9997 SE 82ND AVE
HAPPY VALLEY OR
97086-2301
US

IV. Provider business mailing address

9997 SE 82ND AVE
HAPPY VALLEY OR
97086-2301
US

V. Phone/Fax

Practice location:
  • Phone: 503-224-9009
  • Fax:
Mailing address:
  • Phone: 503-224-9009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number7731
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD12420
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: