Provider Demographics
NPI:1841724481
Name:CHERRY DENTAL OF BEAVERTON
Entity type:Organization
Organization Name:CHERRY DENTAL OF BEAVERTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:KATI
Authorized Official - Last Name:MARECEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-644-1110
Mailing Address - Street 1:8070 SW HALL BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-6419
Mailing Address - Country:US
Mailing Address - Phone:503-567-7461
Mailing Address - Fax:503-641-6431
Practice Address - Street 1:8070 SW HALL BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-6419
Practice Address - Country:US
Practice Address - Phone:503-567-7461
Practice Address - Fax:503-641-6431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental