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General NPI Number Information
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NPI Number | 1215683503
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Entity Type | Organization
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Legal Business Name | IMPACT SLEEP DENTISTRY
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Dates
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Enumeration Date | 02/24/2022
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Last Update Date | 04/29/2022
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Provider Practice Location Address
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Address Line | 3415 SW 187TH AVE
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City | BEAVERTON
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State | OR
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Zip | 97003-3106
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Country | US
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Telephone | 503-649-3101
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Fax |
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Provider Business Mailing Address
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Address Line | 17455 SW HOODOO CT
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City | BEAVERTON
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State | OR
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Zip | 97007-7702
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Country | US
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Telephone | 503-679-5072
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MELIKA KASHKOULI
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Credential | DMD
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Telephone | 503-679-5072
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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 |
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License Number State |
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