Provider Demographics
NPI:1043834997
Name:SY, MOUSTAPHA (DDS)
Entity Type:Individual
Prefix:
First Name:MOUSTAPHA
Middle Name:
Last Name:SY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16755 SW BASELINE RD STE 106
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4284
Mailing Address - Country:US
Mailing Address - Phone:503-352-5450
Mailing Address - Fax:503-746-5448
Practice Address - Street 1:16755 SW BASELINE RD STE 106
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4284
Practice Address - Country:US
Practice Address - Phone:503-352-5450
Practice Address - Fax:503-746-5448
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11230122300000X, 1223G0001X
OR11230122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist