Provider Demographics
NPI:1871030478
Name:DESAI, RIDDHI (DMD)
Entity Type:Individual
Prefix:
First Name:RIDDHI
Middle Name:
Last Name:DESAI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 SW MOODY AVE
Mailing Address - Street 2:SDORTH
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2730 SW MOODY AVE
Practice Address - Street 2:SDORTH
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-5042
Practice Address - Country:US
Practice Address - Phone:503-494-8921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-21
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190319551223X0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program