1174646129 NPI number — PERIO AESTHETICS & IMPLANTOLOGY

Table of content: (NPI 1174646129)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174646129 NPI number — PERIO AESTHETICS & IMPLANTOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERIO AESTHETICS & IMPLANTOLOGY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174646129
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15455 NW GREENBRIER PKWY
Provider Second Line Business Mailing Address:
SUITE 235
Provider Business Mailing Address City Name:
BEAVERTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97006-7374
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-645-3333
Provider Business Mailing Address Fax Number:
503-645-1760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15455 NW GREENBRIER PKWY
Provider Second Line Business Practice Location Address:
SUITE 235
Provider Business Practice Location Address City Name:
BEAVERTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97006-7374
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-645-3333
Provider Business Practice Location Address Fax Number:
503-645-1760
Provider Enumeration Date:
04/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCCLAIN
Authorized Official First Name:
ALEXIS
Authorized Official Middle Name:
K
Authorized Official Title or Position:
FRONT OFFICE COORDINATOR
Authorized Official Telephone Number:
503-645-3333

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X , with the licence number:  D8051 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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