Healthcare Provider Details

I. General information

NPI: 1902100316
Provider Name (Legal Business Name): HUMBLE RICHMOND & RUSSELL ORAL & MAXILLOFACIAL SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2010
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 SE 223RD AVE SUITE 180
GRESHAM OR
97030-2574
US

IV. Provider business mailing address

1201 SE 223RD AVE SUITE 180
GRESHAM OR
97030-2574
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-1431
  • Fax: 503-492-0880
Mailing address:
  • Phone: 503-667-1431
  • Fax: 503-492-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD7053
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD9295
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD6660
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DENISE OLSON
Title or Position: BOOKKEEPER
Credential:
Phone: 503-667-1431