Provider Demographics
NPI:1689698466
Name:RADAKOVICH, JOSEPH J (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:J
Last Name:RADAKOVICH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 NE HOYT ST
Mailing Address - Street 2:SUITE 322
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213
Mailing Address - Country:US
Mailing Address - Phone:503-230-0322
Mailing Address - Fax:503-230-0344
Practice Address - Street 1:5050 NE HOYT ST
Practice Address - Street 2:SUITE 322
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213
Practice Address - Country:US
Practice Address - Phone:503-230-0322
Practice Address - Fax:503-230-0344
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD61951223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR931090894OtherTAX ID
OR931090894OtherTAX ID