Healthcare Provider Details

I. General information

NPI: 1417021262
Provider Name (Legal Business Name): JONATHAN DENTON LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7052 SW NYBERG ST
TUALATIN OR
97062-9231
US

IV. Provider business mailing address

18121 SE RIVER RD # 14-14
MILWAUKIE OR
97267-6021
US

V. Phone/Fax

Practice location:
  • Phone: 503-766-3366
  • Fax: 503-766-3366
Mailing address:
  • Phone: 503-781-2494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number12823
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: