Healthcare Provider Details

I. General information

NPI: 1154746758
Provider Name (Legal Business Name): NEWBERG KIDS DENTIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2014
Last Update Date: 06/20/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2502 E PORTLAND RD
NEWBERG OR
97132-1923
US

IV. Provider business mailing address

2502 E PORTLAND RD
NEWBERG OR
97132-1923
US

V. Phone/Fax

Practice location:
  • Phone: 503-538-4289
  • Fax: 503-538-4352
Mailing address:
  • Phone: 503-538-4289
  • Fax: 503-538-4352

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: NAVID NEWPORT
Title or Position: OWNER/PROVIDER
Credential: DDS
Phone: 360-747-2111