Provider Demographics
NPI:1215626007
Name:MIRZAZADEH JAVAHERI, ARIA (DMD)
Entity type:Individual
Prefix:DR
First Name:ARIA
Middle Name:
Last Name:MIRZAZADEH JAVAHERI
Suffix:
Gender:
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5228 N LOMBARD ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-4326
Mailing Address - Country:US
Mailing Address - Phone:503-289-7043
Mailing Address - Fax:
Practice Address - Street 1:5228 N LOMBARD ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-4326
Practice Address - Country:US
Practice Address - Phone:503-289-7043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-05
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD81123122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes122300000XDental ProvidersDentist