Healthcare Provider Details

I. General information

NPI: 1366157497
Provider Name (Legal Business Name): CASCADE ORAL AND FACIAL SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16455 BOONES FERRY RD STE B
LAKE OSWEGO OR
97035-4367
US

IV. Provider business mailing address

16455 BOONES FERRY RD STE B
LAKE OSWEGO OR
97035-4367
US

V. Phone/Fax

Practice location:
  • Phone: 503-482-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. PHIL MANN
Title or Position: OFFICER
Credential: DDS, MD
Phone: 503-482-7200