Provider Demographics
NPI:1598021578
Name:AZARISAMANI, AMIR (MD, DMD)
Entity Type:Individual
Prefix:
First Name:AMIR
Middle Name:
Last Name:AZARISAMANI
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:AMIR
Other - Middle Name:FARHAD
Other - Last Name:AZARISAMANI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, DMD
Mailing Address - Street 1:1893 NE NEFF RD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6112
Mailing Address - Country:US
Mailing Address - Phone:541-382-7981
Mailing Address - Fax:
Practice Address - Street 1:1893 NE NEFF RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6112
Practice Address - Country:US
Practice Address - Phone:541-382-7981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19828122300000X
ORD97931223S0112X
ORMD187266204E00000X
390200000390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORD9793OtherOREGON BOARD OF DENTISTRY
ORMD187266OtherOREGON BOARD OF MEDICINE