Healthcare Provider Details

I. General information

NPI: 1558526368
Provider Name (Legal Business Name): TY BRADLEY VAUGHAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 NE 5TH ST
GRESHAM OR
97030-7308
US

IV. Provider business mailing address

320 NE 5TH ST
GRESHAM OR
97030-7308
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 TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE 60152137
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD9588
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: