Provider Demographics
NPI:1730491283
Name:OWTAD, POURIA (DMD)
Entity Type:Individual
Prefix:
First Name:POURIA
Middle Name:
Last Name:OWTAD
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 1:2534 E. RIDGE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024
Mailing Address - Country:US
Mailing Address - Phone:520-275-1741
Mailing Address - Fax:
Practice Address - Street 1:9163 W UNION HILLS DR STE 101
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-8187
Practice Address - Country:US
Practice Address - Phone:623-487-1888
Practice Address - Fax:623-487-1888
Is Sole Proprietor?:No
Enumeration Date:2010-07-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ80431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice