Provider Demographics
NPI:1205664844
Name:SUMMIT OREGON LLC
Entity type:Organization
Organization Name:SUMMIT OREGON LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ORAL & MAXILLOFACIAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:PRASHANT
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARUGUNDLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-548-2006
Mailing Address - Street 1:3332 N LOMBARD ST STE C
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-1258
Mailing Address - Country:US
Mailing Address - Phone:503-548-2006
Mailing Address - Fax:503-548-2012
Practice Address - Street 1:3332 N LOMBARD ST STE C
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-1258
Practice Address - Country:US
Practice Address - Phone:503-548-2006
Practice Address - Fax:503-548-2012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-24
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty