Healthcare Provider Details

I. General information

NPI: 1609968007
Provider Name (Legal Business Name): HAZIM DENTAL CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12661 SE POWELL BLVD SUITE E
PORTLAND OR
97236-3400
US

IV. Provider business mailing address

PO BOX 90813
PORTLAND OR
97290-0813
US

V. Phone/Fax

Practice location:
  • Phone: 503-761-1120
  • Fax: 503-774-2622
Mailing address:
  • Phone: 503-761-1120
  • Fax: 503-774-2622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD7022
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. ZIAD ANTONIOUS HAZIM
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 503-761-1120