Provider Demographics
NPI:1225012123
Name:THORESON, EDWIN CHARLES (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:CHARLES
Last Name:THORESON
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:P.O. BOX 929
Mailing Address - Street 2:
Mailing Address - City:ESTACADA
Mailing Address - State:OR
Mailing Address - Zip Code:97023
Mailing Address - Country:US
Mailing Address - Phone:503-630-4219
Mailing Address - Fax:503-630-4238
Practice Address - Street 1:630 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ESTACADA
Practice Address - State:OR
Practice Address - Zip Code:97023-8584
Practice Address - Country:US
Practice Address - Phone:503-630-4219
Practice Address - Fax:503-630-4238
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-04
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD48841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice