Provider Demographics
NPI:1720197429
Name:GANJI, FREDERICK J (DDS)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:J
Last Name:GANJI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16755 SW BASELINE RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4241
Mailing Address - Country:US
Mailing Address - Phone:503-533-4001
Mailing Address - Fax:503-533-4116
Practice Address - Street 1:16755 SW BASELINE RD
Practice Address - Street 2:SUITE 106
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4241
Practice Address - Country:US
Practice Address - Phone:503-533-4001
Practice Address - Fax:503-533-4116
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000101301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5048426Medicaid