1699927863 NPI number — EASTPORT PLAZA DENTAL P.C.

Table of content: (NPI 1699927863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699927863 NPI number — EASTPORT PLAZA DENTAL P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTPORT PLAZA DENTAL P.C.
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:
1699927863
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4410 SE 82ND AVE
Provider Second Line Business Mailing Address:
SUITE 2050
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97266-2941
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-771-0081
Provider Business Mailing Address Fax Number:
503-772-2272

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4410 SE 82ND AVE
Provider Second Line Business Practice Location Address:
SUITE 2050
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97266-2941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-771-0081
Provider Business Practice Location Address Fax Number:
503-772-2272
Provider Enumeration Date:
10/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TON
Authorized Official First Name:
TRUC
Authorized Official Middle Name:
THAT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
503-771-0081

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D7171 , 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)





Copyright © 2007-2024 www.npivalidator.com