Provider Demographics
NPI:1164642161
Name:AUSTRIA, NATHANIEL M
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:M
Last Name:AUSTRIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 918
Mailing Address - Street 2:
Mailing Address - City:SCAPPOOSE
Mailing Address - State:OR
Mailing Address - Zip Code:97056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4732 NW BETHANY BLVD.
Practice Address - Street 2:SUITE G 2
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229
Practice Address - Country:US
Practice Address - Phone:503-617-7384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD-6857122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist