Healthcare Provider Details

I. General information

NPI: 1154119048
Provider Name (Legal Business Name): DENTISTS OF TUALATIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2025
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7552 SW NYBERG ST
TUALATIN OR
97062-9298
US

IV. Provider business mailing address

4885 SW SAUM WAY
TUALATIN OR
97062-6715
US

V. Phone/Fax

Practice location:
  • Phone: 406-498-0617
  • Fax:
Mailing address:
  • Phone: 406-498-0671
  • Fax: 406-498-0671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KRISTA MATTSON
Title or Position: OWNER
Credential: DDS
Phone: 406-498-0671