Provider Demographics
NPI:1598223919
Name:PORTLAND MODERN DENTISTRY, PC
Entity Type:Organization
Organization Name:PORTLAND MODERN DENTISTRY, PC
Other - Org Name:PORTLAND MODERN DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TODD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-845-8500
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:714-845-8500
Mailing Address - Fax:
Practice Address - Street 1:5175 NE MARTIN LUTHER KING BLVD STE 110
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3233
Practice Address - Country:US
Practice Address - Phone:503-406-1108
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-05
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty