Healthcare Provider Details

I. General information

NPI: 1588674964
Provider Name (Legal Business Name): MATTHEW RALPH BAUMGARTH D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10365 SE SUNNYSIDE RD STE 260
CLACKAMAS OR
97015-5707
US

IV. Provider business mailing address

10365 SE SUNNYSIDE RD STE 260
CLACKAMAS OR
97015-5707
US

V. Phone/Fax

Practice location:
  • Phone: 503-698-4484
  • Fax: 503-698-5033
Mailing address:
  • Phone: 503-698-4484
  • Fax: 503-698-5033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD7910
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier11402877
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerSTATE ID #

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: