Provider Demographics
NPI:1114449485
Name:TODD, AUSTIN CHARLES (DDS)
Entity Type:Individual
Prefix:DR
First Name:AUSTIN
Middle Name:CHARLES
Last Name:TODD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 NW 19TH AVE APT 404
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2092
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7017 SW NYBERG ST STE P-46
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-6243
Practice Address - Country:US
Practice Address - Phone:972-974-5602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-08
Last Update Date:2017-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10684122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty