Provider Demographics
NPI:1639604689
Name:PORTLAND DENTAL ANESTHESIA
Entity Type:Organization
Organization Name:PORTLAND DENTAL ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:ALLRED
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-858-4880
Mailing Address - Street 1:21370 SW LANGER FARMS PKWY #142
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-9137
Mailing Address - Country:US
Mailing Address - Phone:503-858-4880
Mailing Address - Fax:503-914-6685
Practice Address - Street 1:21370 SW LANGER FARMS PKWY #142
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9137
Practice Address - Country:US
Practice Address - Phone:503-858-4880
Practice Address - Fax:503-914-6685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD93871223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Single Specialty