Provider Demographics
NPI:1922647312
Name:-
Entity Type:Organization
Organization Name:-
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HUJATULLAH
Authorized Official - Middle Name:
Authorized Official - Last Name:BAYAT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:503-363-6500
Mailing Address - Street 1:4342 LIBERTY RD S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-6171
Mailing Address - Country:US
Mailing Address - Phone:503-363-6500
Mailing Address - Fax:
Practice Address - Street 1:4342 LIBERTY RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-6171
Practice Address - Country:US
Practice Address - Phone:503-363-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4342OtherOWNER