Provider Demographics
NPI:1043581465
Name:RIVERPLACE PERIODONTICS PC
Entity Type:Organization
Organization Name:RIVERPLACE PERIODONTICS PC
Other - Org Name:RIVERPLACE PERIODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DUY ANH
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-654-5405
Mailing Address - Street 1:2636 SE HARRISON STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222
Mailing Address - Country:US
Mailing Address - Phone:503-654-5405
Mailing Address - Fax:
Practice Address - Street 1:2636 SE HARRISON STREET
Practice Address - Street 2:SUITE A
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222
Practice Address - Country:US
Practice Address - Phone:503-654-5405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-17
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD73601223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty