Healthcare Provider Details

I. General information

NPI: 1073227294
Provider Name (Legal Business Name): MOONLIGHT SLEEP REMEDIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2023
Last Update Date: 02/05/2026
Certification Date: 02/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 SW 10TH AVE STE 1212
PORTLAND OR
97205-2713
US

IV. Provider business mailing address

511 SW 10TH AVE STE 1212
PORTLAND OR
97205-2713
US

V. Phone/Fax

Practice location:
  • Phone: 503-505-4624
  • Fax:
Mailing address:
  • Phone: 503-505-4624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. MIKA MIYAMOTO
Title or Position: DENTIST / OWNER
Credential: DMD
Phone: 503-705-8648