Provider Demographics
NPI:1639103658
Name:COLUMBIA PARK ORAL SURGERY PC
Entity Type:Organization
Organization Name:COLUMBIA PARK ORAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOONING
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-289-9621
Mailing Address - Street 1:3549 N LOMBARD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-5901
Mailing Address - Country:US
Mailing Address - Phone:503-289-9621
Mailing Address - Fax:503-289-2930
Practice Address - Street 1:3549 N LOMBARD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-5901
Practice Address - Country:US
Practice Address - Phone:503-289-9621
Practice Address - Fax:503-289-2930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD60811223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty