Healthcare Provider Details

I. General information

NPI: 1285842385
Provider Name (Legal Business Name): MODERN FAMILY DENTAL OF TROUTDALE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25603 SE STARK ST
TROUTDALE OR
97060-3305
US

IV. Provider business mailing address

25603 SE STARK ST
TROUTDALE OR
97060-3305
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-8889
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: NATHAN LEE
Title or Position: DENTIST
Credential: DDS
Phone: 503-667-8889