Provider Demographics
NPI:1720240427
Name:PEDIATRIC DENTISTRY, RC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY, RC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER OF PRACTICE
Authorized Official - Prefix:
Authorized Official - First Name:NOEL
Authorized Official - Middle Name:V
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-284-5678
Mailing Address - Street 1:2824 NE WASCO ST
Mailing Address - Street 2:SUITE 230
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1772
Mailing Address - Country:US
Mailing Address - Phone:503-284-5678
Mailing Address - Fax:
Practice Address - Street 1:2824 NE WASCO ST
Practice Address - Street 2:SUITE 230
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1772
Practice Address - Country:US
Practice Address - Phone:503-284-5678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD68531223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty