Provider Demographics
NPI:1124583208
Name:PORTLAND DENTAL LLC
Entity Type:Organization
Organization Name:PORTLAND DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KAVEENDRA
Authorized Official - Middle Name:THUSHARA
Authorized Official - Last Name:RANASINGHE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-227-1693
Mailing Address - Street 1:511 SW 10TH AVE STE 1206
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2713
Mailing Address - Country:US
Mailing Address - Phone:503-227-1693
Mailing Address - Fax:503-227-2362
Practice Address - Street 1:511 SW 10TH AVE STE 1206
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2713
Practice Address - Country:US
Practice Address - Phone:503-227-1693
Practice Address - Fax:503-227-2362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty