Provider Demographics
NPI:1306024880
Name:AVENUE DENTAL CARE
Entity Type:Organization
Organization Name:AVENUE DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHADEEP
Authorized Official - Middle Name:S
Authorized Official - Last Name:VIRK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-786-3000
Mailing Address - Street 1:10001 SE SUNNYSIDE RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5746
Mailing Address - Country:US
Mailing Address - Phone:503-786-3000
Mailing Address - Fax:
Practice Address - Street 1:10001 SE SUNNYSIDE RD
Practice Address - Street 2:SUITE 250
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5746
Practice Address - Country:US
Practice Address - Phone:503-786-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8233122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty