Healthcare Provider Details

I. General information

NPI: 1780234575
Provider Name (Legal Business Name): THOMAS D. CARDWELL, DMD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2019
Last Update Date: 09/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11400 SE 37TH AVE
MILWAUKIE OR
97222-5982
US

IV. Provider business mailing address

1825 SW ELM ST APT 4
PORTLAND OR
97201-7602
US

V. Phone/Fax

Practice location:
  • Phone: 503-774-6355
  • Fax:
Mailing address:
  • Phone: 503-913-6193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. THOMAS CARDWELL
Title or Position: PRESIDENT
Credential: DMD
Phone: 503-913-6193