Provider Demographics
NPI:1710136221
Name:FRIENDLY SMILES DENTAL GROUP
Entity Type:Organization
Organization Name:FRIENDLY SMILES DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-232-3102
Mailing Address - Street 1:2505 SE HAWTHORNE BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3970
Mailing Address - Country:US
Mailing Address - Phone:503-232-3102
Mailing Address - Fax:
Practice Address - Street 1:2505 SE HAWTHORNE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3970
Practice Address - Country:US
Practice Address - Phone:503-232-3102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8843122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty