Provider Demographics
NPI:1396912010
Name:BARNES DENTAL LLC
Entity type:Organization
Organization Name:BARNES DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:SOBALVARRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-297-8866
Mailing Address - Street 1:7325 SW BARNES RD
Mailing Address - Street 2:BARNES DENTAL LLC
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225
Mailing Address - Country:US
Mailing Address - Phone:503-297-8866
Mailing Address - Fax:503-384-9366
Practice Address - Street 1:7325 SW BARNES RD
Practice Address - Street 2:BARNES DENTAL LLC
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225
Practice Address - Country:US
Practice Address - Phone:503-297-8866
Practice Address - Fax:503-384-9366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD75131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR158908Medicaid