Healthcare Provider Details

I. General information

NPI: 1407134596
Provider Name (Legal Business Name): FAIROUZ CHOUIKH DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2011
Last Update Date: 03/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 N GANTENBEIN AVE
PORTLAND OR
97227-1623
US

IV. Provider business mailing address

982 AVE. WILFRID-PELLETIER APT. 304
STE-FOY QC
G1W 4Y2
CA

V. Phone/Fax

Practice location:
  • Phone: 503-413-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD10993
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: