Provider Demographics
NPI:1255704813
Name:PERLEDENT DENTAL CARE, PC
Entity type:Organization
Organization Name:PERLEDENT DENTAL CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:H
Authorized Official - Last Name:VAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-533-4001
Mailing Address - Street 1:16755 SW BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4241
Mailing Address - Country:US
Mailing Address - Phone:503-533-4001
Mailing Address - Fax:
Practice Address - Street 1:16755 SW BASELINE RD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4241
Practice Address - Country:US
Practice Address - Phone:503-533-4001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10365122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty