Provider Demographics
NPI:1093086415
Name:BRIDGEPORT DENTAL LLC
Entity Type:Organization
Organization Name:BRIDGEPORT DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:GEROGE
Authorized Official - Middle Name:
Authorized Official - Last Name:KANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-906-8600
Mailing Address - Street 1:18035 SW LOWER BOONES FERRY RD
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7228
Mailing Address - Country:US
Mailing Address - Phone:503-906-8600
Mailing Address - Fax:503-716-4607
Practice Address - Street 1:18035 SW LOWER BOONES FERRY RD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7228
Practice Address - Country:US
Practice Address - Phone:503-906-8600
Practice Address - Fax:503-716-4607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental