Provider Demographics
NPI:1922310242
Name:ROSE CITY DENTAL CARE LLC
Entity Type:Organization
Organization Name:ROSE CITY DENTAL CARE LLC
Other - Org Name:ROSE CITY DENTAL CARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER- GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-255-2415
Mailing Address - Street 1:2341 SE 122ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233
Mailing Address - Country:US
Mailing Address - Phone:503-255-2415
Mailing Address - Fax:503-261-0565
Practice Address - Street 1:2341 SE 122ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233
Practice Address - Country:US
Practice Address - Phone:503-255-2415
Practice Address - Fax:503-261-0565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-02
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7463122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty