Provider Demographics
NPI:1346791308
Name:EMERGENCY DENTIST OF MILWAUKIE INC
Entity Type:Organization
Organization Name:EMERGENCY DENTIST OF MILWAUKIE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-644-1126
Mailing Address - Street 1:18807 SE MCLOUGHLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-6735
Mailing Address - Country:US
Mailing Address - Phone:503-644-1126
Mailing Address - Fax:503-644-0692
Practice Address - Street 1:18807 SE MCLOUGHLIN BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-6735
Practice Address - Country:US
Practice Address - Phone:503-644-1126
Practice Address - Fax:503-644-0692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD74631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty