Provider Demographics
NPI:1124701479
Name:MOSHARRAF, HESAM (DMD)
Entity type:Individual
Prefix:DR
First Name:HESAM
Middle Name:
Last Name:MOSHARRAF
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2028 NE THORNCROFT DR APT 1431
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-9041
Mailing Address - Country:US
Mailing Address - Phone:602-505-3749
Mailing Address - Fax:
Practice Address - Street 1:3514 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1821
Practice Address - Country:US
Practice Address - Phone:503-616-4330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-11
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11874122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist