Healthcare Provider Details

I. General information

NPI: 1891450185
Provider Name (Legal Business Name): ZOLA DENTAL RALEIGH PARK LLC, DR. ANTHONY PAVENTY DMD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2021
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8568 SW APPLE WAY
PORTLAND OR
97225-1772
US

IV. Provider business mailing address

8568 SW APPLE WAY
PORTLAND OR
97225-1772
US

V. Phone/Fax

Practice location:
  • Phone: 503-292-6773
  • Fax: 503-292-6773
Mailing address:
  • Phone: 503-292-6773
  • Fax: 503-292-6773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CRISTINA WATERMAN
Title or Position: ASSOCIATE DENTIST
Credential: DDS
Phone: 503-292-6773