Basic Information
| Provider Information | |||||||||
| NPI: | 1740288174 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHARRAZI | ||||||||
| FirstName: | SHEIDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6950 NE CAMPUS WAY | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971245611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1855433682 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1107 NE BURNSIDE RD | ||||||||
| Address2: | |||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970305710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036659616 | ||||||||
| FaxNumber: | 5036660852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2005 | ||||||||
| LastUpdateDate: | 07/09/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/16/2006 | ||||||||
| NPIReactivationDate: | 03/30/2006 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | D7585 | OR | Y | Dental Providers | Dentist | General Practice |
No ID Information.