Healthcare Provider Details

I. General information

NPI: 1992307367
Provider Name (Legal Business Name): FIRST IMPRESSIONS DENTURE STUDIO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2020
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NE 20TH AVE STE 100
PORTLAND OR
97232-3094
US

IV. Provider business mailing address

200 NE 20TH AVE STE 100
PORTLAND OR
97232-3094
US

V. Phone/Fax

Practice location:
  • Phone: 503-230-0207
  • Fax: 503-230-0208
Mailing address:
  • Phone: 503-230-0207
  • Fax: 503-230-0208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License Number
License Number State

VIII. Authorized Official

Name: DAVID PETTIT
Title or Position: OPERATIONS DIRECTOR
Credential:
Phone: 503-230-0207