Healthcare Provider Details

I. General information

NPI: 1689675167
Provider Name (Legal Business Name): EASTSIDE DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date: 01/03/2007
Reactivation Date: 01/30/2007

III. Provider practice location address

1540 SW 257TH AVE
TROUTDALE OR
97060-7412
US

IV. Provider business mailing address

PO BOX 700
TROUTDALE OR
97060-0700
US

V. Phone/Fax

Practice location:
  • Phone: 503-665-2177
  • Fax: 503-666-7130
Mailing address:
  • Phone: 503-665-2177
  • Fax: 503-666-7130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateOR

VIII. Authorized Official

Name: DR. JOHN H KILIAN
Title or Position: DENTIST OWNER
Credential: DMD
Phone: 503-665-2177