Healthcare Provider Details

I. General information

NPI: 1144231879
Provider Name (Legal Business Name): AZITA ZADEH PTDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17803 NW DEERFIELD DR
PORTLAND OR
97229-1778
US

IV. Provider business mailing address

17803 NW DEERFIELD DR
PORTLAND OR
97229-1778
US

V. Phone/Fax

Practice location:
  • Phone: 503-614-8579
  • Fax:
Mailing address:
  • Phone: 503-614-8579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number114606
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: