Provider Demographics
NPI:1881256766
Name:ELDOMIATY, WALIED (DDS)
Entity type:Individual
Prefix:DR
First Name:WALIED
Middle Name:
Last Name:ELDOMIATY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4055 MERCANTILE DR APT 374
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-2633
Mailing Address - Country:US
Mailing Address - Phone:202-285-8313
Mailing Address - Fax:
Practice Address - Street 1:4055 MERCANTILE DR APT 374
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2633
Practice Address - Country:US
Practice Address - Phone:202-285-8313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-01
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9897122300000X
ORD116961223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentist
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty