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General NPI Number Information
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NPI Number | 1881256766
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Entity Type | Individual
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Provider Name | WALIED ELDOMIATY DDS
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Gender | Male
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Dates
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Enumeration Date | 07/01/2019
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Last Update Date | 04/10/2023
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Provider Practice Location Address
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Address Line | 4055 MERCANTILE DR APT 374
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City | LAKE OSWEGO
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State | OR
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Zip | 97035-2633
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Country | US
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Telephone | 202-285-8313
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Fax |
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Provider Business Mailing Address
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Address Line | 4055 MERCANTILE DR APT 374
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City | LAKE OSWEGO
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State | OR
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Zip | 97035-2633
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Country | US
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Telephone | 202-285-8313
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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 | 9897
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | D11696
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License Number State | OR
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