Provider Demographics
NPI:1457784555
Name:BACKOWSKI, NICHOLAS R (DMD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:R
Last Name:BACKOWSKI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36840 INDUSTRIAL WAY B
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:OR
Mailing Address - Zip Code:97055-9254
Mailing Address - Country:US
Mailing Address - Phone:503-668-1300
Mailing Address - Fax:
Practice Address - Street 1:2038 LLOYD CTR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1309
Practice Address - Country:US
Practice Address - Phone:503-288-5361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9941122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist