Healthcare Provider Details

I. General information

NPI: 1699833772
Provider Name (Legal Business Name): ALIREZA FARID BOLOURI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11103 SE MAIN ST SUITE B
MILWAUKIE OR
97222
US

IV. Provider business mailing address

11103 SE MAIN ST SUITE B
MILWAUKIE OR
97222
US

V. Phone/Fax

Practice location:
  • Phone: 503-654-0613
  • Fax: 503-654-4087
Mailing address:
  • Phone: 503-654-0613
  • Fax: 503-654-4087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD6808
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: