Provider Demographics
NPI:1689929838
Name:PORTLAND DENTAL CENTER
Entity Type:Organization
Organization Name:PORTLAND DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MAN
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:CHAU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-331-1322
Mailing Address - Street 1:4301 NE TILLAMOOK ST.
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1315
Mailing Address - Country:US
Mailing Address - Phone:503-331-1322
Mailing Address - Fax:503-331-1252
Practice Address - Street 1:4301 NE TILLAMOOK ST.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1315
Practice Address - Country:US
Practice Address - Phone:503-331-1322
Practice Address - Fax:503-331-1252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9662122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty