Provider Demographics
NPI:1215683503
Name:IMPACT SLEEP DENTISTRY
Entity type:Organization
Organization Name:IMPACT SLEEP DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:KASHKOULI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-679-5072
Mailing Address - Street 1:17455 SW HOODOO CT
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-7702
Mailing Address - Country:US
Mailing Address - Phone:503-679-5072
Mailing Address - Fax:
Practice Address - Street 1:3415 SW 187TH AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97003-3106
Practice Address - Country:US
Practice Address - Phone:503-649-3101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-24
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty