Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | DN19828 | FL |
Y | 1223S0112X | Oral and Maxillofacial Surgeon | D9793 | OR |
N | 204E00000X | Oral & Maxillofacial Surgeon | MD187266 | OR |
NPI | 1598021578 |
---|---|
Provider Name | Amir Azarisamani |
First Address | Bend, OR 97701-6112 |
Second Address | Bend, OR 97701-6112 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/04/2012 |
Last Update Date | 27/08/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D9793 | OREGON BOARD OF DENTISTRY (01) | OR |
MD187266 | OREGON BOARD OF MEDICINE (01) | OR |