Basic Information
| Provider Information | |||||||||
| NPI: | 1518090323 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PORTLAND DENTAL ASSOCIATES PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TEAMSTERS DENTAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1890 NE 162ND AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972305642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032579836 | ||||||||
| FaxNumber: | 5032573723 | ||||||||
| Practice Location | |||||||||
| Address1: | 1890 NE 162ND AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972305642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032579836 | ||||||||
| FaxNumber: | 5032573723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOLOURI | ||||||||
| AuthorizedOfficialFirstName: | FARID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DENTAL DIRECTOR DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 5032579836 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DMD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.