Provider Demographics
NPI:1912340241
Name:MEHDI L. GHAVAM, D.M.D. L.L.C.
Entity Type:Organization
Organization Name:MEHDI L. GHAVAM, D.M.D. L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MEHDI
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GHAVAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-890-1950
Mailing Address - Street 1:3200 ANDERSON CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TALENT
Mailing Address - State:OR
Mailing Address - Zip Code:97540-7733
Mailing Address - Country:US
Mailing Address - Phone:541-890-1950
Mailing Address - Fax:541-512-2601
Practice Address - Street 1:106 N MARKET ST
Practice Address - Street 2:
Practice Address - City:TALENT
Practice Address - State:OR
Practice Address - Zip Code:97540-0265
Practice Address - Country:US
Practice Address - Phone:541-890-1950
Practice Address - Fax:541-512-2601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-17
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8425261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental