Provider Demographics
NPI:1881860914
Name:GLADSTONE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:GLADSTONE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KATO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-657-3077
Mailing Address - Street 1:1105 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-2170
Mailing Address - Country:US
Mailing Address - Phone:503-657-3077
Mailing Address - Fax:503-655-5729
Practice Address - Street 1:1105 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-2170
Practice Address - Country:US
Practice Address - Phone:503-657-3077
Practice Address - Fax:503-655-5729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8790261QD0000X
ORD6082261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental