Provider Demographics
NPI:1518332923
Name:TROUTDALE DENTAL LLC
Entity Type:Organization
Organization Name:TROUTDALE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRYANT
Authorized Official - Middle Name:
Authorized Official - Last Name:ZOLLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-648-6671
Mailing Address - Street 1:324 SE 9TH AVE STE B
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4247
Mailing Address - Country:US
Mailing Address - Phone:503-648-6671
Mailing Address - Fax:
Practice Address - Street 1:191 E HISTORIC COLUMBIA RIVER HWY
Practice Address - Street 2:
Practice Address - City:TROUTDALE
Practice Address - State:OR
Practice Address - Zip Code:97060-2076
Practice Address - Country:US
Practice Address - Phone:503-674-8767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST DENTAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD100361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty