Provider Demographics
NPI:1467909333
Name:BAHTA, GHEBRE
Entity Type:Individual
Prefix:
First Name:GHEBRE
Middle Name:
Last Name:BAHTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16513 NE 40TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-5635
Mailing Address - Country:US
Mailing Address - Phone:503-888-5594
Mailing Address - Fax:
Practice Address - Street 1:16155 NW CORNELL RD STE 450
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-8101
Practice Address - Country:US
Practice Address - Phone:503-629-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH4571124Q00000X
WAHL60004995124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist