Healthcare Provider Details

I. General information

NPI: 1790017804
Provider Name (Legal Business Name): SAMIR KUMAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2010
Last Update Date: 02/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12450 SW PIONEER LN STE B
BEAVERTON OR
97008-8377
US

IV. Provider business mailing address

12450 SW PIONEER LN STE B
BEAVERTON OR
97008-8377
US

V. Phone/Fax

Practice location:
  • Phone: 503-590-8883
  • Fax: 503-590-0955
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD7769
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: