Provider Demographics
NPI:1124548235
Name:DECA DENTISTRY
Entity Type:Organization
Organization Name:DECA DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BEATRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:DECA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-267-9400
Mailing Address - Street 1:501 NE HOOD AVE STE 235
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030
Mailing Address - Country:US
Mailing Address - Phone:503-661-4900
Mailing Address - Fax:
Practice Address - Street 1:501 NE HOOD AVE STE 235
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7346
Practice Address - Country:US
Practice Address - Phone:503-661-4900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD103761223E0200X
ORD103771223G0001X
1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty