Healthcare Provider Details

I. General information

NPI: 1699126532
Provider Name (Legal Business Name): TYLER BRADSTREET
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23479 SE STARK ST STE. 102
GRESHAM OR
97030-2962
US

IV. Provider business mailing address

14740 NW CORNELL RD STE 120
PORTLAND OR
97229-5400
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-1184
  • Fax:
Mailing address:
  • Phone: 503-690-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD10466
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: