Provider Demographics
NPI:1407210578
Name:BRADLEY E SIEVERT DMD PC
Entity Type:Organization
Organization Name:BRADLEY E SIEVERT DMD PC
Other - Org Name:WESTLAKE FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:SIEVERT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-636-4576
Mailing Address - Street 1:16016 BOONES FERRY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-4357
Mailing Address - Country:US
Mailing Address - Phone:503-636-4576
Mailing Address - Fax:503-697-5069
Practice Address - Street 1:16016 BOONES FERRY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4357
Practice Address - Country:US
Practice Address - Phone:503-636-4576
Practice Address - Fax:503-697-5069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7780332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies