Provider Demographics
NPI:1407134596
Name:CHOUIKH, FAIROUZ (DMD)
Entity Type:Individual
Prefix:
First Name:FAIROUZ
Middle Name:
Last Name:CHOUIKH
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 1:982 AVE. WILFRID-PELLETIER
Mailing Address - Street 2:APT. 304
Mailing Address - City:STE-FOY
Mailing Address - State:QC
Mailing Address - Zip Code:G1W 4Y2
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2801 N GANTENBEIN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1623
Practice Address - Country:US
Practice Address - Phone:503-413-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-24
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD109931223S0112X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery