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General NPI Number Information
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NPI Number | 1184617516
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Entity Type | Organization
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Legal Business Name | BEAVERTON DENTAL ARTS LLC
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Dates
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Enumeration Date | 08/31/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 12751 SW 2ND ST
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City | BEAVERTON
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State | OR
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Zip | 97005-2708
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Country | US
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Telephone | 503-644-3312
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Fax | 503-644-1713
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Provider Business Mailing Address
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Address Line | 12751 SW 2ND ST
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City | BEAVERTON
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State | OR
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Zip | 97005-2708
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Country | US
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Telephone | 503-644-3312
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Fax | 503-644-1713
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Authorized Official
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Title or Position | MEMBER
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Name | DR. THAO D NGUYEN
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Credential | DMD
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Telephone | 503-644-3312
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D7199
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License Number State | OR
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