Provider Demographics
NPI:1083749907
Name:ENAYATI, MEHRAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MEHRAN
Middle Name:
Last Name:ENAYATI
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 1:15280 NW CENTRAL DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-7805
Mailing Address - Country:US
Mailing Address - Phone:503-533-8240
Mailing Address - Fax:503-533-8320
Practice Address - Street 1:15280 NW CENTRAL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-7805
Practice Address - Country:US
Practice Address - Phone:503-533-8240
Practice Address - Fax:503-533-8320
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD70391223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORD7039OtherDENTAL LICENSE NUMBER