Provider Demographics
NPI:1124390281
Name:WESTSIDE PERIODONTICS & IMPLANTOLOGY LLC
Entity Type:Organization
Organization Name:WESTSIDE PERIODONTICS & IMPLANTOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VAHID
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:ESHRAGHI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-799-5383
Mailing Address - Street 1:9934 NW SKYLINE HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-2634
Mailing Address - Country:US
Mailing Address - Phone:503-799-5383
Mailing Address - Fax:
Practice Address - Street 1:9934 NW SKYLINE HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-2634
Practice Address - Country:US
Practice Address - Phone:503-799-5383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8855261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental