Provider Demographics
NPI:1134439144
Name:DELLA CROCE, MIRA KHAROTI (DMD)
Entity type:Individual
Prefix:DR
First Name:MIRA
Middle Name:KHAROTI
Last Name:DELLA CROCE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MIRA
Other - Middle Name:
Other - Last Name:KHAROTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1791 NW 173RD AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-5630
Mailing Address - Country:US
Mailing Address - Phone:503-372-5527
Mailing Address - Fax:
Practice Address - Street 1:1791 NW 173RD AVE STE 110
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-5630
Practice Address - Country:US
Practice Address - Phone:503-372-5527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-13
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10523122300000X
PADS0382601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist