Provider Demographics
NPI:1477562296
Name:FUN, KAYVANDOKHT (RDH)
Entity Type:Individual
Prefix:
First Name:KAYVANDOKHT
Middle Name:
Last Name:FUN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11894 SW ASPEN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-2561
Mailing Address - Country:US
Mailing Address - Phone:503-598-0672
Mailing Address - Fax:
Practice Address - Street 1:19075 NW TANASBOURNE DR STE 300
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-5860
Practice Address - Country:US
Practice Address - Phone:503-531-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH2379124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR124Q00000XOtherDENTAL HYGIENIST