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General NPI Number Information
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NPI Number | 1063729523
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Entity Type | Individual
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Provider Name | MASTANEH POURNADERI D.D.S
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Gender | Female
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Dates
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Enumeration Date | 09/04/2010
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Last Update Date | 09/04/2010
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Provider Practice Location Address
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Address Line | 12710 SE DIVISION ST
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City | PORTLAND
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State | OR
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Zip | 97236-3134
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Country | US
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Telephone | 503-988-3410
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Fax |
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Provider Business Mailing Address
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Address Line | 14820 NW TRANQUILITY DR
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City | BANKS
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State | OR
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Zip | 97106-8835
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Country | US
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Telephone | 503-324-0631
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D8516
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 42083
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License Number State | CA
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