Healthcare Provider Details

I. General information

NPI: 1225771108
Provider Name (Legal Business Name): ICP TELEDENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3439 SE HAWTHORNE BLVD # 906
PORTLAND OR
97214-5048
US

IV. Provider business mailing address

3439 SE HAWTHORNE BLVD # 906
PORTLAND OR
97214-5048
US

V. Phone/Fax

Practice location:
  • Phone: 425-494-0883
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code125J00000X
TaxonomyDental Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MR. CHANDAN SHARMA
Title or Position: HOD
Credential:
Phone: 425-494-0883