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General NPI Number Information
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NPI Number | 1306009881
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Entity Type | Individual
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Provider Name | KELLY ANN DEZURA D.M.D.
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Gender | Female
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Dates
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Enumeration Date | 07/06/2008
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Last Update Date | 08/28/2013
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Provider Practice Location Address
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Address Line | 10181 SE SUNNYSIDE RD OTOLARYNGOLOGY (ENT)
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City | CLACKAMAS
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State | OR
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Zip | 97015
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Country | US
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Telephone | 510-571-4727
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Fax |
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Provider Business Mailing Address
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Address Line | 3717 NE 12TH AVE
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City | PORTLAND
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State | OR
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Zip | 97212-1241
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Country | US
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Telephone | 419-306-6443
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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 | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | D9858
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License Number State | OR
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