Provider Demographics
NPI:1689675167
Name:EASTSIDE DENTAL CLINIC
Entity Type:Organization
Organization Name:EASTSIDE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:KILIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-665-2177
Mailing Address - Street 1:PO BOX 700
Mailing Address - Street 2:
Mailing Address - City:TROUTDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97060-0700
Mailing Address - Country:US
Mailing Address - Phone:503-665-2177
Mailing Address - Fax:503-666-7130
Practice Address - Street 1:1540 SW 257TH AVE
Practice Address - Street 2:
Practice Address - City:TROUTDALE
Practice Address - State:OR
Practice Address - Zip Code:97060-7412
Practice Address - Country:US
Practice Address - Phone:503-665-2177
Practice Address - Fax:503-666-7130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2022-07-21
Deactivation Date:2007-01-03
Deactivation Code:
Reactivation Date:2007-01-30
Provider Licenses
StateLicense IDTaxonomies
OR1223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
131109Medicare ID - Type Unspecified