Provider Demographics
NPI:1700192184
Name:NE 82ND AVENUE DENTAL LLC
Entity Type:Organization
Organization Name:NE 82ND AVENUE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-254-0897
Mailing Address - Street 1:2150 NE 82ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-5607
Mailing Address - Country:US
Mailing Address - Phone:503-254-0897
Mailing Address - Fax:503-254-0894
Practice Address - Street 1:2150 NE 82ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-5607
Practice Address - Country:US
Practice Address - Phone:503-254-0897
Practice Address - Fax:503-254-0894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8506261QD0000X
ORD9389261QD0000X
ORD8961261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental