Provider Demographics
NPI:1669759767
Name:HERITAGE DENTAL
Entity type:Organization
Organization Name:HERITAGE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:CRANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-231-8228
Mailing Address - Street 1:4511 SE HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3195
Mailing Address - Country:US
Mailing Address - Phone:503-231-8228
Mailing Address - Fax:503-231-5634
Practice Address - Street 1:4511 SE HAWTHORNE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-3195
Practice Address - Country:US
Practice Address - Phone:503-231-8228
Practice Address - Fax:503-231-5634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-03
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9096261QD0000X
OR5651261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental