Provider Demographics
NPI:1518998533
Name:BRAVOSMILE PC
Entity Type:Organization
Organization Name:BRAVOSMILE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:M
Authorized Official - Last Name:CANDEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-222-3591
Mailing Address - Street 1:2075 SW 1ST AVE STE 2K
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5314
Mailing Address - Country:US
Mailing Address - Phone:503-222-3591
Mailing Address - Fax:503-222-4496
Practice Address - Street 1:2075 SW 1ST AVE STE 2K
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-5314
Practice Address - Country:US
Practice Address - Phone:503-222-3591
Practice Address - Fax:503-222-4496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty