Healthcare Provider Details

I. General information

NPI: 1023367513
Provider Name (Legal Business Name): BEAVERTON DENTAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2012
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11673 SW BEAVERTON HILLSDALE HWY
BEAVERTON OR
97005-2928
US

IV. Provider business mailing address

11673 SW BEAVERTON HILLSDALE HWY
BEAVERTON OR
97005-2928
US

V. Phone/Fax

Practice location:
  • Phone: 503-641-4328
  • Fax: 503-644-8454
Mailing address:
  • Phone: 503-641-4328
  • Fax: 503-644-8454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122400000X
TaxonomyDenturist
License Number27130
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2004
License Number StateOR

VIII. Authorized Official

Name: JOHN WILLIAMS
Title or Position: OWNER
Credential:
Phone: 503-641-4328