Healthcare Provider Details

I. General information

NPI: 1487819116
Provider Name (Legal Business Name): NORTHWEST ENDODONTICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18395 SW ALEXANDER ST
ALOHA OR
97006-3961
US

IV. Provider business mailing address

18395 SW ALEXANDER ST
ALOHA OR
97006-3961
US

V. Phone/Fax

Practice location:
  • Phone: 503-642-4552
  • Fax: 503-591-0202
Mailing address:
  • Phone: 503-642-4552
  • Fax: 503-591-0202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD7495
License Number StateOR

VIII. Authorized Official

Name: DR. PAUL DAVID BRENT
Title or Position: OWNER
Credential: D.D.S.
Phone: 503-642-4552