Provider Demographics
NPI:1144231879
Name:ZADEH, AZITA (PTDA)
Entity Type:Individual
Prefix:
First Name:AZITA
Middle Name:
Last Name:ZADEH
Suffix:
Gender:F
Credentials:PTDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17803 NW DEERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-1778
Mailing Address - Country:US
Mailing Address - Phone:503-614-8579
Mailing Address - Fax:
Practice Address - Street 1:17803 NW DEERFIELD DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-1778
Practice Address - Country:US
Practice Address - Phone:503-614-8579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR114606126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant