Provider Demographics
NPI:1295811180
Name:PARKROSE FAMILY DENTISTRY, P.C.
Entity type:Organization
Organization Name:PARKROSE FAMILY DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:THANH
Authorized Official - Last Name:TIEU
Authorized Official - Suffix:II
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-254-5575
Mailing Address - Street 1:3620 NE 122ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-1365
Mailing Address - Country:US
Mailing Address - Phone:503-254-5575
Mailing Address - Fax:503-254-2162
Practice Address - Street 1:3620 NE 122ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-1365
Practice Address - Country:US
Practice Address - Phone:503-254-5575
Practice Address - Fax:503-254-2162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7324122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORD7324OtherSTATE LICENSE NUMBER