Healthcare Provider Details

I. General information

NPI: 1871602417
Provider Name (Legal Business Name): MAHMOUD MAGHSOUDLOU DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 07/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7095 SW GONZAGA ST
TIGARD OR
97223-8309
US

IV. Provider business mailing address

6950 NE CAMPUS WAY
HILLSBORO OR
97124-5611
US

V. Phone/Fax

Practice location:
  • Phone: 503-952-2000
  • Fax:
Mailing address:
  • Phone: 503-952-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD7365
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: