Provider Demographics
NPI:1699027672
Name:CLACKAMAS TOWN DENTAL, LLC
Entity Type:Organization
Organization Name:CLACKAMAS TOWN DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCES
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-880-8581
Mailing Address - Street 1:9225 SE SUNNYSIDE ROAD
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9225 SE SUNNYSIDE ROAD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97086
Practice Address - Country:US
Practice Address - Phone:503-905-3380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty