Provider Demographics
NPI:1508484205
Name:DENTAL PROFESSIONALS OF OREGON, P.C.
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF OREGON, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TABATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-6078
Mailing Address - Street 1:12850 SW CANYON RD STE A
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2166
Mailing Address - Country:US
Mailing Address - Phone:503-376-8537
Mailing Address - Fax:
Practice Address - Street 1:12850 SW CANYON RD STE A
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2166
Practice Address - Country:US
Practice Address - Phone:503-376-8537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF OREGON, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty