Provider Demographics
NPI:1780140715
Name:TIMBER DENTAL EAST BURNSIDE
Entity type:Organization
Organization Name:TIMBER DENTAL EAST BURNSIDE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-419-6288
Mailing Address - Street 1:1200 SE SANDY BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1347
Mailing Address - Country:US
Mailing Address - Phone:503-419-6499
Mailing Address - Fax:
Practice Address - Street 1:1200 SE SANDY BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1347
Practice Address - Country:US
Practice Address - Phone:503-419-6499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-14
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1295143212OtherNPI
1639504715OtherNPI
1821225442OtherNPI
1851845036OtherNPI
1952684169OtherNPI
1780605287OtherNPI
1033404751OtherNPI
1144213802OtherNPI