Provider Demographics
NPI:1558078600
Name:A. FARID BOLOURI DMD, PC
Entity Type:Organization
Organization Name:A. FARID BOLOURI DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:IRMA
Authorized Official - Middle Name:
Authorized Official - Last Name:STARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-654-0613
Mailing Address - Street 1:11080 SE OAK ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-6692
Mailing Address - Country:US
Mailing Address - Phone:503-654-0613
Mailing Address - Fax:
Practice Address - Street 1:11080 SE OAK ST
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6692
Practice Address - Country:US
Practice Address - Phone:503-654-0613
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-28
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty