Provider Demographics
NPI:1821203522
Name:SUNNYBROOK FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:SUNNYBROOK FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIEM
Authorized Official - Middle Name:Q
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-427-0427
Mailing Address - Street 1:11411 SE SUNNYSIDE RD, SUITE 102
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086
Mailing Address - Country:US
Mailing Address - Phone:503-427-0427
Mailing Address - Fax:503-427-2782
Practice Address - Street 1:11411 SE SUNNYSIDE RD, SUITE 102
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086
Practice Address - Country:US
Practice Address - Phone:503-427-0427
Practice Address - Fax:503-427-2782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD71951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty