Provider Demographics
NPI:1376068478
Name:WORLD OF SMILES TEEN DENTISTRY LLC
Entity Type:Organization
Organization Name:WORLD OF SMILES TEEN DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PATIENT FINANCIAL COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:WENDI
Authorized Official - Middle Name:
Authorized Official - Last Name:TJOSTOLVSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-626-9711
Mailing Address - Street 1:4548 N ALBINA AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-3010
Mailing Address - Country:US
Mailing Address - Phone:503-626-9711
Mailing Address - Fax:503-894-8869
Practice Address - Street 1:11790 SW BARNES RD STE 220
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5934
Practice Address - Country:US
Practice Address - Phone:503-626-9700
Practice Address - Fax:503-626-9772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-09
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9074122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty