Healthcare Provider Details

I. General information

NPI: 1730365479
Provider Name (Legal Business Name): JULIANA BRANCO DACOSTA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2008
Last Update Date: 01/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 SW CAMPUS DR
PORTLAND OR
97239-3001
US

IV. Provider business mailing address

15690 SW PEACHTREE DR
TIGARD OR
97224-0997
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-4316
  • Fax: 503-494-8384
Mailing address:
  • Phone: 503-758-2162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDF0021
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: