Provider Demographics
NPI:1265557789
Name:SLEEP DENTISTRY OF PORTLAND LLC
Entity type:Organization
Organization Name:SLEEP DENTISTRY OF PORTLAND LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:C
Authorized Official - Last Name:KASCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-666-9519
Mailing Address - Street 1:19265 SE STARK ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-5758
Mailing Address - Country:US
Mailing Address - Phone:503-666-9519
Mailing Address - Fax:
Practice Address - Street 1:19265 SE STARK ST
Practice Address - Street 2:SUITE A
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-5758
Practice Address - Country:US
Practice Address - Phone:503-666-9519
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH1529124Q00000X
ORD81261223G0001X
ORD86481223G0001X
ORD45281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty