Provider Demographics
NPI:1740553106
Name:BRIDGEPORT FAMILY DENTAL, LLC
Entity type:Organization
Organization Name:BRIDGEPORT FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-430-7909
Mailing Address - Street 1:7420 SW BRIDGEPORT RD STE 104
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7790
Mailing Address - Country:US
Mailing Address - Phone:503-430-7909
Mailing Address - Fax:503-268-1501
Practice Address - Street 1:7420 SW BRIDGEPORT RD STE 104
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7790
Practice Address - Country:US
Practice Address - Phone:503-430-7909
Practice Address - Fax:503-268-1501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7482122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty