Provider Demographics
NPI:1699524629
Name:RIKHTEHGAR BERENJI, HESSAM (LD)
Entity type:Individual
Prefix:
First Name:HESSAM
Middle Name:
Last Name:RIKHTEHGAR BERENJI
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63140 BRITTA ST STE D104
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-5738
Mailing Address - Country:US
Mailing Address - Phone:629-999-5014
Mailing Address - Fax:
Practice Address - Street 1:150 SE 3RD AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4019
Practice Address - Country:US
Practice Address - Phone:503-213-1257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-TMP-10234898122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist