Provider Demographics
NPI:1568785848
Name:THE FRIENDS OF CRESTON CHILDREN'S DENTAL CLINIC
Entity Type:Organization
Organization Name:THE FRIENDS OF CRESTON CHILDREN'S DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:LORA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MATTSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-513-5010
Mailing Address - Street 1:10505 SE 17TH AVE
Mailing Address - Street 2:MULTNOMAH DENTAL SOCIETY
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-7475
Mailing Address - Country:US
Mailing Address - Phone:503-513-5010
Mailing Address - Fax:
Practice Address - Street 1:4701 SE BUSH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-3283
Practice Address - Country:US
Practice Address - Phone:503-916-5808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-01
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD5168251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable