Healthcare Provider Details

I. General information

NPI: 1285902619
Provider Name (Legal Business Name): ROBERT JOSEPH KOWAL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 01/24/2014
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

387 NE 223RD AVE
GRESHAM OR
97030-8554
US

V. Phone/Fax

Practice location:
  • Phone: 503-491-5450
  • Fax:
Mailing address:
  • Phone: 503-491-5450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD9936
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: