Provider Demographics
NPI:1487859344
Name:MEZA, OTTO F (LD)
Entity Type:Individual
Prefix:MR
First Name:OTTO
Middle Name:F
Last Name:MEZA
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18324 TIMBERGROVE CT
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-8228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1547 N PACIFIC HWY
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-3656
Practice Address - Country:US
Practice Address - Phone:503-981-4001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-DO-460587122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR127352OtherDIV. MED. ASST. PROGRAMS
ORDT-DO-460587OtherOREGON HEALTH LICENSING #