Healthcare Provider Details

I. General information

NPI: 1902022783
Provider Name (Legal Business Name): ENDODONTIC SPECIALTY GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 NW EASTMAN PKWY SUITE 265
GRESHAM OR
97030-3858
US

IV. Provider business mailing address

1550 NW EASTMAN PKWY SUITE 265
GRESHAM OR
97030-3858
US

V. Phone/Fax

Practice location:
  • Phone: 503-665-0495
  • Fax: 503-674-9196
Mailing address:
  • Phone: 503-665-0495
  • Fax: 503-674-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: DALE BARKER
Title or Position: PRESIDENT
Credential: DDS
Phone: 503-665-0495