Provider Demographics
NPI:1750300687
Name:GOTTLIEB, SAMUEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12401 SHELBY CT
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-1102
Mailing Address - Country:US
Mailing Address - Phone:503-245-0384
Mailing Address - Fax:
Practice Address - Street 1:17675 SW TUALATIN VALLEY HWY
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4443
Practice Address - Country:US
Practice Address - Phone:503-259-3160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD72451223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics