Provider Demographics
NPI:1699818088
Name:SANDY DENTAL CLINIC PC
Entity Type:Organization
Organization Name:SANDY DENTAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KHIET
Authorized Official - Middle Name:MINH
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-646-5230
Mailing Address - Street 1:12520 SW 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-0550
Mailing Address - Country:US
Mailing Address - Phone:503-646-5230
Mailing Address - Fax:503-626-1813
Practice Address - Street 1:12520 SW 1ST ST
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-0550
Practice Address - Country:US
Practice Address - Phone:503-646-5230
Practice Address - Fax:503-626-1813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD67091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty