Healthcare Provider Details

I. General information

NPI: 1538614458
Provider Name (Legal Business Name): DIVISION FAMILY DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

2484 NE DIVISION ST
GRESHAM OR
97030-6020
US

IV. Provider business mailing address

2484 NE DIVISION ST
GRESHAM OR
97030-6020
US

V. Phone/Fax

Practice location:
  • Phone: 503-559-6533
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD10228
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. TERESA NGUYEN
Title or Position: DENTIST
Credential: DMD
Phone: 503-559-6533