Healthcare Provider Details

I. General information

NPI: 1538183348
Provider Name (Legal Business Name): BENJAMIN ADAM NIELSEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 NE MULTNOMAH ST SUITE 880
PORTLAND OR
97232-2131
US

IV. Provider business mailing address

14938 SE STANHOPE RD
CLACKAMAS OR
97015-5413
US

V. Phone/Fax

Practice location:
  • Phone: 503-230-1234
  • Fax: 503-239-7741
Mailing address:
  • Phone: 503-558-8428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD8379
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: