1104156959 NPI number — SUNNYSIDE DENTISTRY FOR CHILDREN, P.C.

Table of content: (NPI 1104156959)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104156959 NPI number — SUNNYSIDE DENTISTRY FOR CHILDREN, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNNYSIDE DENTISTRY FOR CHILDREN, 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:
1104156959
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11411 SE SUNNYSIDE RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
CLACKAMAS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97015-5713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-855-5100
Provider Business Mailing Address Fax Number:
503-826-5196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11411 SE SUNNYSIDE RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
CLACKAMAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97015-5745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-855-5100
Provider Business Practice Location Address Fax Number:
503-826-5196
Provider Enumeration Date:
12/29/2009

Additional Information

Authorized Official

Authorized Official Last Name:
DOYLE, JR
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
503-855-5100

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  D6490 , 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)

  • Identifier: 005996 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com