Healthcare Provider Details

I. General information

NPI: 1508854241
Provider Name (Legal Business Name): SHUFANG AMY LAI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2442 SE 101ST AVE SUITE 303
PORTLAND OR
97216-3060
US

IV. Provider business mailing address

2442 SE 101ST AVENUE SUITE 303
PORTLAND OR
94216-3060
US

V. Phone/Fax

Practice location:
  • Phone: 503-253-7579
  • Fax: 503-253-7579
Mailing address:
  • Phone: 503-253-7579
  • Fax: 503-253-7579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number06632
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: