Provider Demographics
NPI:1275259418
Name:COLASURDODMD LLC
Entity Type:Organization
Organization Name:COLASURDODMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:COLASURDO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-680-2972
Mailing Address - Street 1:4969 SW 31ST DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-1239
Mailing Address - Country:US
Mailing Address - Phone:503-680-2972
Mailing Address - Fax:
Practice Address - Street 1:833 SW 11TH AVE STE 723
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2121
Practice Address - Country:US
Practice Address - Phone:503-223-7661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty