Provider Demographics
NPI:1104029446
Name:TIGARD DENTAL
Entity Type:Organization
Organization Name:TIGARD DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:J
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-684-9017
Mailing Address - Street 1:12720 SW PACIFIC HWY STE 2
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6125
Mailing Address - Country:US
Mailing Address - Phone:503-684-9017
Mailing Address - Fax:
Practice Address - Street 1:12720 SW PACIFIC HWY STE 2
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6125
Practice Address - Country:US
Practice Address - Phone:503-684-9017
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR78621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1205049251OtherNPI