Provider Demographics
NPI:1699833772
Name:BOLOURI, ALIREZA FARID (DMD)
Entity Type:Individual
Prefix:MR
First Name:ALIREZA
Middle Name:FARID
Last Name:BOLOURI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11103 SE MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222
Mailing Address - Country:US
Mailing Address - Phone:503-654-0613
Mailing Address - Fax:503-654-4087
Practice Address - Street 1:11103 SE MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222
Practice Address - Country:US
Practice Address - Phone:503-654-0613
Practice Address - Fax:503-654-4087
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD68081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice