Healthcare Provider Details

I. General information

NPI: 1689093213
Provider Name (Legal Business Name): THE DENTURE STUDIO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21511 SE STARK ST
GRESHAM OR
97030-2025
US

IV. Provider business mailing address

21511 SE STARK ST
GRESHAM OR
97030-2025
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-1698
  • Fax:
Mailing address:
  • Phone: 503-666-1698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: RONALD FARRIS
Title or Position: DENTURIST
Credential:
Phone: 503-666-1698