Provider Demographics
NPI:1538707294
Name:LAKE OSWEGO MODERN DENTISTRY, PC
Entity Type:Organization
Organization Name:LAKE OSWEGO MODERN DENTISTRY, PC
Other - Org Name:LAKE OSWEGO MODERN DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DARIOUSH
Authorized Official - Middle Name:
Authorized Official - Last Name:AFSHAR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-334-0351
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:714-845-8500
Mailing Address - Fax:
Practice Address - Street 1:4823 MEADOWS RD STE 131
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2622
Practice Address - Country:US
Practice Address - Phone:503-334-0351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-12
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty