Provider Demographics
NPI:1063729523
Name:POURNADERI, MASTANEH (DDS)
Entity type:Individual
Prefix:DR
First Name:MASTANEH
Middle Name:
Last Name:POURNADERI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14820 NW TRANQUILITY DR
Mailing Address - Street 2:
Mailing Address - City:BANKS
Mailing Address - State:OR
Mailing Address - Zip Code:97106-8835
Mailing Address - Country:US
Mailing Address - Phone:503-324-0631
Mailing Address - Fax:
Practice Address - Street 1:12710 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-3134
Practice Address - Country:US
Practice Address - Phone:503-988-3410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-04
Last Update Date:2010-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8516122300000X
CA42083122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist