Provider Demographics
NPI:1891386074
Name:MENA, MARIAM (BDS, MSOFPOM)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:MENA
Suffix:
Gender:F
Credentials:BDS, MSOFPOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 SE 141ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-2208
Mailing Address - Country:US
Mailing Address - Phone:503-888-9538
Mailing Address - Fax:
Practice Address - Street 1:618 SE 141ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-2208
Practice Address - Country:US
Practice Address - Phone:503-888-9538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA610696991223X2210X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223X2210XDental ProvidersDentistOrofacial Pain