Provider Demographics
NPI:1114910726
Name:ROSTAMIAN, MOJGAN (DMD)
Entity Type:Individual
Prefix:
First Name:MOJGAN
Middle Name:
Last Name:ROSTAMIAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 SW MULTNOMAH BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-3999
Mailing Address - Country:US
Mailing Address - Phone:503-246-8011
Mailing Address - Fax:503-246-0772
Practice Address - Street 1:2350 SW MULTNOMAH BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-3999
Practice Address - Country:US
Practice Address - Phone:503-246-8011
Practice Address - Fax:503-246-0772
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD65371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice