Provider Demographics
NPI:1073676037
Name:EXCEPTIONAL NEEDS DENTAL SERVICES (ENDS)
Entity Type:Organization
Organization Name:EXCEPTIONAL NEEDS DENTAL SERVICES (ENDS)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:AYRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-295-1201
Mailing Address - Street 1:12029 NE SUMNER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-9015
Mailing Address - Country:US
Mailing Address - Phone:503-295-1201
Mailing Address - Fax:503-295-1211
Practice Address - Street 1:12029 NE SUMNER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-9015
Practice Address - Country:US
Practice Address - Phone:503-295-1201
Practice Address - Fax:503-295-1211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR821498302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR086020Medicaid