Provider Demographics
NPI:1659889822
Name:JMB DENTAL PC
Entity Type:Organization
Organization Name:JMB DENTAL PC
Other - Org Name:MT. HOOD FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-804-2275
Mailing Address - Street 1:15230 SE 82ND DR
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-9606
Mailing Address - Country:US
Mailing Address - Phone:503-655-9000
Mailing Address - Fax:
Practice Address - Street 1:15230 SE 82ND DR
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9606
Practice Address - Country:US
Practice Address - Phone:503-655-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10243261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1528449402OtherDENTIST-GENERAL