Provider Demographics
NPI:1275610495
Name:CENTER STREET DENTAL PC
Entity Type:Organization
Organization Name:CENTER STREET DENTAL PC
Other - Org Name:JOHNATHAN TODD COOK DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-656-8287
Mailing Address - Street 1:419 CENTER STREET
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-2211
Mailing Address - Country:US
Mailing Address - Phone:503-656-8287
Mailing Address - Fax:503-656-8375
Practice Address - Street 1:419 CENTER STREET
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-2211
Practice Address - Country:US
Practice Address - Phone:503-656-8287
Practice Address - Fax:503-656-8375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD74531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty