1104902667 NPI number — NORTHWEST DENTAL ASSOCIATES, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104902667 NPI number — NORTHWEST DENTAL ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST DENTAL ASSOCIATES, PC
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:
6
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:
1104902667
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 SANDPOINTE AVE
Provider Second Line Business Mailing Address:
8TH FLOOR
Provider Business Mailing Address City Name:
SANTA ANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92707-5778
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-428-1300
Provider Business Mailing Address Fax Number:
714-428-1390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4655 SW GRIFFITH DR
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
BEAVERTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97005-8711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-644-1400
Provider Business Practice Location Address Fax Number:
503-646-1913
Provider Enumeration Date:
10/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MONTENEGRO
Authorized Official First Name:
ARACELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR MANAGER
Authorized Official Telephone Number:
714-578-6358

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D9255 , 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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