Healthcare Provider Details

I. General information

NPI: 1134177934
Provider Name (Legal Business Name): DAVID M. TEETER DMD, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10102 NE GLISAN ST
PORTLAND OR
97220-4456
US

IV. Provider business mailing address

11172 SE CEDAR WAY
PORTLAND OR
97236-6291
US

V. Phone/Fax

Practice location:
  • Phone: 503-257-5959
  • Fax:
Mailing address:
  • Phone: 503-698-3753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD6368
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number37066
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: