Provider Demographics
NPI:1639577182
Name:HEDAYAT, LALEH
Entity Type:Individual
Prefix:
First Name:LALEH
Middle Name:
Last Name:HEDAYAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 SW MOODY AVE
Mailing Address - Street 2:SCHOOL OF DENTISTRY
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5042
Mailing Address - Country:US
Mailing Address - Phone:503-330-7235
Mailing Address - Fax:
Practice Address - Street 1:16055 SW REGATTA LN
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-8303
Practice Address - Country:US
Practice Address - Phone:503-330-7235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR55474122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist