Provider Demographics
NPI:1225771108
Name:ICP TELEDENTISTRY
Entity Type:Organization
Organization Name:ICP TELEDENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HOD
Authorized Official - Prefix:MR
Authorized Official - First Name:CHANDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-494-0883
Mailing Address - Street 1:3439 SE HAWTHORNE BLVD # 906
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3439 SE HAWTHORNE BLVD # 906
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-5048
Practice Address - Country:US
Practice Address - Phone:425-494-0883
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No125J00000XDental ProvidersDental TherapistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA006880293OtherDL