Healthcare Provider Details

I. General information

NPI: 1700201464
Provider Name (Legal Business Name): BROOKSIDE DENTAL-GRESHAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2014
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4255 SE 182ND AVE
GRESHAM OR
97030-5083
US

IV. Provider business mailing address

4255 SE 182ND AVE
GRESHAM OR
97030-5083
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-2515
  • Fax: 503-618-9254
Mailing address:
  • Phone: 503-666-2515
  • Fax: 503-618-9254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberD7444
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. BRIAN REED WESTOVER
Title or Position: OWNER/DENTIST
Credential: D,M,D
Phone: 503-723-8722