Provider Demographics
NPI:1710172267
Name:ST JOHNS DENTAL ARTS PC
Entity Type:Organization
Organization Name:ST JOHNS DENTAL ARTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-286-3669
Mailing Address - Street 1:8407 N LOMBARD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203
Mailing Address - Country:US
Mailing Address - Phone:503-286-3669
Mailing Address - Fax:503-286-3660
Practice Address - Street 1:8407 N LOMBARD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203
Practice Address - Country:US
Practice Address - Phone:503-286-3669
Practice Address - Fax:503-286-3660
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST JOHNS DENTAL ARTS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR297948Medicare UPIN