Provider Demographics
NPI:1700201464
Name:BROOKSIDE DENTAL-GRESHAM
Entity Type:Organization
Organization Name:BROOKSIDE DENTAL-GRESHAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:REED
Authorized Official - Last Name:WESTOVER
Authorized Official - Suffix:
Authorized Official - Credentials:D,M,D
Authorized Official - Phone:503-723-8722
Mailing Address - Street 1:4255 SE 182ND AVE
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-5083
Mailing Address - Country:US
Mailing Address - Phone:503-666-2515
Mailing Address - Fax:503-618-9254
Practice Address - Street 1:4255 SE 182ND AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5083
Practice Address - Country:US
Practice Address - Phone:503-666-2515
Practice Address - Fax:503-618-9254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD74441223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty