Healthcare Provider Details

I. General information

NPI: 1093009706
Provider Name (Legal Business Name): K. DAVID CARNEIRO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2011
Last Update Date: 05/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 EXCHANGE ST
ASTORIA OR
97103-3508
US

IV. Provider business mailing address

1775 EXCHANGE ST
ASTORIA OR
97103-3508
US

V. Phone/Fax

Practice location:
  • Phone: 503-325-3533
  • Fax: 503-325-3609
Mailing address:
  • Phone: 503-325-3533
  • Fax: 503-325-3609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number7028
License Number StateOR

VIII. Authorized Official

Name: SANDRA R OSTERHOLME
Title or Position: OFFICE MANAGER
Credential: EFDA
Phone: 503-325-3533