Healthcare Provider Details

I. General information

NPI: 1760728786
Provider Name (Legal Business Name): GRESHAM MODERN DENTISTRY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2012
Last Update Date: 12/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

387 NE 223RD AVE
GRESHAM OR
97030-8554
US

IV. Provider business mailing address

17000 RED HILL AVE
IRVINE CA
92614-5626
US

V. Phone/Fax

Practice location:
  • Phone: 503-491-5450
  • Fax: 503-491-5452
Mailing address:
  • Phone: 714-845-8890
  • Fax: 949-474-1495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. RICHARD I ASHTON II
Title or Position: OWNER DOCTOR
Credential: DMD
Phone: 503-491-5450