Provider Demographics
NPI:1225458441
Name:PORTLAND CHILDREN'S DENTISTRY, LLC
Entity Type:Organization
Organization Name:PORTLAND CHILDREN'S DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:RAPHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-893-2889
Mailing Address - Street 1:2323 NW WESTOVER RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3524
Mailing Address - Country:US
Mailing Address - Phone:503-893-2889
Mailing Address - Fax:
Practice Address - Street 1:2323 NW WESTOVER RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3524
Practice Address - Country:US
Practice Address - Phone:503-893-2889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-27
Last Update Date:2014-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9732261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental