Provider Demographics
NPI:1962638205
Name:COLUMBIA SQUARE DENTAL LLC
Entity Type:Organization
Organization Name:COLUMBIA SQUARE DENTAL LLC
Other - Org Name:GREEN APPLE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:HT
Authorized Official - Last Name:KANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-224-0588
Mailing Address - Street 1:1320 SW 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5833
Mailing Address - Country:US
Mailing Address - Phone:503-224-0133
Mailing Address - Fax:503-224-4750
Practice Address - Street 1:1320 SW 2ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-5833
Practice Address - Country:US
Practice Address - Phone:503-224-0133
Practice Address - Fax:503-224-4750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-01
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8506122300000X
ORD9083122300000X
ORD9163122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty