Provider Demographics
NPI:1376889758
Name:AZITA SHAHGALDI DMD LLC
Entity Type:Organization
Organization Name:AZITA SHAHGALDI DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:AZITA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAHGALDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-246-7999
Mailing Address - Street 1:9600 SW CAPITOL HWY
Mailing Address - Street 2:140
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-5295
Mailing Address - Country:US
Mailing Address - Phone:503-246-7999
Mailing Address - Fax:503-546-2976
Practice Address - Street 1:9600 SW CAPITOL HWY
Practice Address - Street 2:140
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-5295
Practice Address - Country:US
Practice Address - Phone:503-246-7999
Practice Address - Fax:503-546-2976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9511261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental