Provider Demographics
NPI:1528546330
Name:CHRISTOPHER BRADY DMD LLC
Entity Type:Organization
Organization Name:CHRISTOPHER BRADY DMD LLC
Other - Org Name:ADVANCED DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/AUTHORIZED SIGNER
Authorized Official - Prefix:
Authorized Official - First Name:PAVEL
Authorized Official - Middle Name:IVANOVICH
Authorized Official - Last Name:SARANCHUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-902-4300
Mailing Address - Street 1:4707 NE 102ND AVE STE A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-3393
Mailing Address - Country:US
Mailing Address - Phone:971-867-2956
Mailing Address - Fax:
Practice Address - Street 1:4707 NE 102ND AVE STE A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3393
Practice Address - Country:US
Practice Address - Phone:971-867-2956
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10185261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental