Provider Demographics
NPI:1144237728
Name:MT. SCOTT FAMILY DENTAL, LLC
Entity Type:Organization
Organization Name:MT. SCOTT FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-353-9000
Mailing Address - Street 1:12100 SE STEVENS COURT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086
Mailing Address - Country:US
Mailing Address - Phone:503-353-9000
Mailing Address - Fax:503-786-1873
Practice Address - Street 1:12100 SE STEVENS COURT
Practice Address - Street 2:SUITE 101
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086
Practice Address - Country:US
Practice Address - Phone:503-353-9000
Practice Address - Fax:503-786-1873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD6577122300000X, 1223G0001X
ORD8599122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty