Healthcare Provider Details

I. General information

NPI: 1497830053
Provider Name (Legal Business Name): JOHN CRAIG BAUMGARTNER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 SW CAMPUS DR ROOM 19
PORTLAND OR
97239-3001
US

IV. Provider business mailing address

5900 SUNCREEK DR
LAKE OSWEGO OR
97035-8779
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-4316
  • Fax: 503-494-8384
Mailing address:
  • Phone: 503-639-6264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD6760
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: