1427594118 NPI number — PORTLAND EMERGENCY DENTAL CARE USA PC

Table of content: (NPI 1427594118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427594118 NPI number — PORTLAND EMERGENCY DENTAL CARE USA PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORTLAND EMERGENCY DENTAL CARE USA 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:
EMERGENCY DENTAL CARE USA
Provider Other Organization Name Type Code:
3
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:
1427594118
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4245 S 143RD CIR
Provider Second Line Business Mailing Address:
STE. 7
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68137-4516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-393-2726
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8401 NE HALSEY ST
Provider Second Line Business Practice Location Address:
STE 12
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97220-5670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-234-9911
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/18/2017

Additional Information

Authorized Official

Authorized Official Last Name:
OBENG
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
402-393-2726

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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