Provider Demographics
NPI:1023367513
Name:BEAVERTON DENTAL CENTER LLC
Entity Type:Organization
Organization Name:BEAVERTON DENTAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-641-4328
Mailing Address - Street 1:11673 SW BEAVERTON HILLSDALE HWY
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2928
Mailing Address - Country:US
Mailing Address - Phone:503-641-4328
Mailing Address - Fax:503-644-8454
Practice Address - Street 1:11673 SW BEAVERTON HILLSDALE HWY
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2928
Practice Address - Country:US
Practice Address - Phone:503-641-4328
Practice Address - Fax:503-644-8454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20041223G0001X
OR27130122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122400000XDental ProvidersDenturistGroup - Multi-Specialty