Healthcare Provider Details

I. General information

NPI: 1124571369
Provider Name (Legal Business Name): MAIN STREET DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2016
Last Update Date: 07/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 N MAIN AVE
GRESHAM OR
97030-5538
US

IV. Provider business mailing address

810 N MAIN AVE
GRESHAM OR
97030-5538
US

V. Phone/Fax

Practice location:
  • Phone: 503-665-8283
  • Fax: 503-669-7263
Mailing address:
  • Phone: 503-665-8283
  • Fax: 503-669-7263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD10345
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: KATE HARMSTON
Title or Position: OFFICE MANAGER
Credential:
Phone: 503-665-8283