1376068478 NPI number — WORLD OF SMILES TEEN DENTISTRY LLC

Table of content: DR. ALFRED DONALD TROTTER JR. MD FACS (NPI 1285613125)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376068478 NPI number — WORLD OF SMILES TEEN DENTISTRY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WORLD OF SMILES TEEN DENTISTRY LLC
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:
1376068478
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4548 N ALBINA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97217-3010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-626-9711
Provider Business Mailing Address Fax Number:
503-894-8869

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11790 SW BARNES RD STE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97225-5934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-626-9700
Provider Business Practice Location Address Fax Number:
503-626-9772
Provider Enumeration Date:
08/09/2017

Additional Information

Authorized Official

Authorized Official Last Name:
TJOSTOLVSON
Authorized Official First Name:
WENDI
Authorized Official Middle Name:
Authorized Official Title or Position:
PATIENT FINANCIAL COORDINATOR
Authorized Official Telephone Number:
503-626-9711

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D9074 , 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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