Healthcare Provider Details

I. General information

NPI: 1124548235
Provider Name (Legal Business Name): DECA DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 NE HOOD AVE STE 235
GRESHAM OR
97030-7346
US

IV. Provider business mailing address

501 NE HOOD AVE STE 235
GRESHAM OR
97030
US

V. Phone/Fax

Practice location:
  • Phone: 503-661-4900
  • Fax:
Mailing address:
  • Phone: 503-661-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD10376
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD10377
License Number StateOR

VIII. Authorized Official

Name: DR. BEATRICE DECA
Title or Position: DENTIST/ OWNER
Credential: DMD
Phone: 503-267-9400