Provider Demographics
NPI:1417385857
Name:NORTHWEST ORAL AND MAXILLOFACIAL SURGEONS
Entity Type:Organization
Organization Name:NORTHWEST ORAL AND MAXILLOFACIAL SURGEONS
Other - Org Name:BEACON ORAL AND MAXILLOFACIAL SURGEONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:A
Authorized Official - Last Name:LIEBLICK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-665-7882
Mailing Address - Street 1:24850 SE STARK ST STE 100
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-8317
Mailing Address - Country:US
Mailing Address - Phone:503-665-7882
Mailing Address - Fax:503-665-6983
Practice Address - Street 1:24850 SE STARK ST STE 100
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-8317
Practice Address - Country:US
Practice Address - Phone:503-665-7882
Practice Address - Fax:503-665-6983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-22
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD83421223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORT68273Medicare UPIN
OR028415Medicare UPIN
WA602977992Medicare UPIN