Provider Demographics
NPI: | 1891212908 |
---|---|
Name: | PORTLAND ORTHODONTIC GROUP |
Entity Type: | Organization |
Organization Name: | PORTLAND ORTHODONTIC GROUP |
Other - Org Name: | YAILLEN ORTHODONTIC GROUP |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JENNIFER |
Authorized Official - Middle Name: | J |
Authorized Official - Last Name: | CROWE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 503-641-9100 |
Mailing Address - Street 1: | 742 NW MURRAY BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | PORTLAND |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97229-5870 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 503-641-9100 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 742 NW MURRAY BLVD |
Practice Address - Street 2: | |
Practice Address - City: | PORTLAND |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97229-5870 |
Practice Address - Country: | US |
Practice Address - Phone: | 503-641-9100 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-08-29 |
Last Update Date: | 2022-07-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OR | D8844 | 261QD0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QD0000X | Ambulatory Health Care Facilities | Clinic/Center | Dental |