Provider Demographics
NPI:1174646129
Name:PERIO AESTHETICS & IMPLANTOLOGY
Entity Type:Organization
Organization Name:PERIO AESTHETICS & IMPLANTOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRONT OFFICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCCLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-645-3333
Mailing Address - Street 1:15455 NW GREENBRIER PKWY
Mailing Address - Street 2:SUITE 235
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-7374
Mailing Address - Country:US
Mailing Address - Phone:503-645-3333
Mailing Address - Fax:503-645-1760
Practice Address - Street 1:15455 NW GREENBRIER PKWY
Practice Address - Street 2:SUITE 235
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-7374
Practice Address - Country:US
Practice Address - Phone:503-645-3333
Practice Address - Fax:503-645-1760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD80511223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty