Provider Demographics
NPI:1043693617
Name:ANSARI, PARISA
Entity Type:Individual
Prefix:
First Name:PARISA
Middle Name:
Last Name:ANSARI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 E 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-0640
Mailing Address - Country:US
Mailing Address - Phone:541-463-5206
Mailing Address - Fax:
Practice Address - Street 1:2460 WILLAMETTE ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97405-3169
Practice Address - Country:US
Practice Address - Phone:541-463-5206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10270122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist