Healthcare Provider Details

I. General information

NPI: 1649492851
Provider Name (Legal Business Name): JAMES ANTHONY DECOSTA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19300 SW BOONES FERRY RD #8
TUALATIN OR
97062
US

IV. Provider business mailing address

19300 SW BOONES FERRY RD #8
TUALATIN OR
97062
US

V. Phone/Fax

Practice location:
  • Phone: 503-692-0650
  • Fax: 503-692-6787
Mailing address:
  • Phone: 503-692-0650
  • Fax: 503-692-6787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD5807
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: