Provider Demographics
NPI:1205821154
Name:EDVALSON, TIMOTHY JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOHN
Last Name:EDVALSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 DOUGLAS WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-3446
Mailing Address - Country:US
Mailing Address - Phone:503-636-8446
Mailing Address - Fax:503-636-4446
Practice Address - Street 1:3900 DOUGLAS WAY
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3446
Practice Address - Country:US
Practice Address - Phone:503-636-8446
Practice Address - Fax:503-636-4446
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD58251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice