Provider Demographics
NPI:1609837574
Name:OREGON HEALTH & SCIENCE UNIVERSITY
Entity Type:Organization
Organization Name:OREGON HEALTH & SCIENCE UNIVERSITY
Other - Org Name:DIAGNOSTIC LAB OHSU DENTISTRY SCH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-494-8904
Mailing Address - Street 1:PO BOX 10076
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91410-0076
Mailing Address - Country:US
Mailing Address - Phone:805-578-8300
Mailing Address - Fax:805-578-8950
Practice Address - Street 1:2730 SW MOODY AVE
Practice Address - Street 2:SD-PATH
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-5042
Practice Address - Country:US
Practice Address - Phone:503-494-8904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-30
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA182769Medicaid
CA182769Medicaid