Provider Demographics
NPI:1972666956
Name:DAVID A. GOLDWYN, DDS, PC
Entity Type:Organization
Organization Name:DAVID A. GOLDWYN, DDS, PC
Other - Org Name:PORTLAND PERIODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOLDWYN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-245-0180
Mailing Address - Street 1:2350 SW MULTNOMAH BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-3999
Mailing Address - Country:US
Mailing Address - Phone:503-245-0180
Mailing Address - Fax:
Practice Address - Street 1:2350 SW MULTNOMAH BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-3999
Practice Address - Country:US
Practice Address - Phone:503-245-0180
Practice Address - Fax:503-452-3634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD80101223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty