Provider Demographics
NPI:1700982451
Name:SOUTHEAST DENTAL PC
Entity Type:Organization
Organization Name:SOUTHEAST DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OSAMA
Authorized Official - Middle Name:S
Authorized Official - Last Name:BETROUS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-760-7983
Mailing Address - Street 1:12661 SE POWELL
Mailing Address - Street 2:D
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-3400
Mailing Address - Country:US
Mailing Address - Phone:503-760-7983
Mailing Address - Fax:503-762-2379
Practice Address - Street 1:12661 SE POWELL
Practice Address - Street 2:D
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-3900
Practice Address - Country:US
Practice Address - Phone:503-760-7983
Practice Address - Fax:503-762-2379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD6838122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty