Provider Demographics
NPI:1265067615
Name:KONKIN, IVAN JOHN
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:JOHN
Last Name:KONKIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12661 SE POWELL BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-3400
Mailing Address - Country:US
Mailing Address - Phone:503-655-4007
Mailing Address - Fax:
Practice Address - Street 1:12661 SE POWELL BLVD STE C
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-3400
Practice Address - Country:US
Practice Address - Phone:503-655-4007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-05
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-DO-10204635122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty