Provider Demographics
NPI:1659546547
Name:GRESHAM DOWNTOWN DENTAL GROUP, P.C.
Entity Type:Organization
Organization Name:GRESHAM DOWNTOWN DENTAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TRENT
Authorized Official - Middle Name:MILES
Authorized Official - Last Name:WESTOVER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-666-5484
Mailing Address - Street 1:320 NE 5TH ST
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7308
Mailing Address - Country:US
Mailing Address - Phone:503-666-5484
Mailing Address - Fax:503-661-1069
Practice Address - Street 1:320 NE 5TH ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7308
Practice Address - Country:US
Practice Address - Phone:503-666-5484
Practice Address - Fax:503-661-1069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR68681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR=========OtherTAX ID NUMBER FOR THE GROUP