Provider Demographics
NPI:1447276969
Name:SAFFARI, REZA (DMD)
Entity type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:SAFFARI
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:PO BOX 1775
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-1775
Mailing Address - Country:US
Mailing Address - Phone:503-753-6675
Mailing Address - Fax:
Practice Address - Street 1:900 SE CHKALOV DR
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-5240
Practice Address - Country:US
Practice Address - Phone:360-896-1449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4906T1223G0001X
ORD82371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100509684Medicaid
OR298504Medicaid