Provider Demographics
NPI:1639504715
Name:TIMBER DENTAL LLC
Entity Type:Organization
Organization Name:TIMBER DENTAL LLC
Other - Org Name:TIMBER DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:KATHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:971-506-3407
Mailing Address - Street 1:5400 NE RODNEY AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-2642
Mailing Address - Country:US
Mailing Address - Phone:971-506-3407
Mailing Address - Fax:
Practice Address - Street 1:3500 NE MLK
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-2093
Practice Address - Country:US
Practice Address - Phone:971-506-3407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9561122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty