Provider Demographics
NPI:1093138893
Name:OREGON MOBILE DENTISTRY, P.C.
Entity Type:Organization
Organization Name:OREGON MOBILE DENTISTRY, P.C.
Other - Org Name:OREGON MOBILE DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-616-5000
Mailing Address - Street 1:11820 SW KING JAMES PL STE 10J
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-2481
Mailing Address - Country:US
Mailing Address - Phone:503-616-5000
Mailing Address - Fax:
Practice Address - Street 1:11820 SW KING JAMES PL STE 10J
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-2481
Practice Address - Country:US
Practice Address - Phone:503-616-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1223G0001X122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR080858Medicaid