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General NPI Number Information
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NPI Number | 1376991240
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Entity Type | Organization
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Legal Business Name | ADVANCED DENTAL ARTS NW
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Dates
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Enumeration Date | 06/01/2016
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Last Update Date | 06/01/2016
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Provider Practice Location Address
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Address Line | 1316 SW 13TH AVE
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City | PORTLAND
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State | OR
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Zip | 97201
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Country | US
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Telephone | 503-235-0555
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Fax | 503-224-5726
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Provider Business Mailing Address
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Address Line | 1316 SW 13TH AVE
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City | PORTLAND
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State | OR
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Zip | 97201
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Country | US
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Telephone | 503-235-0555
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Fax | 503-224-5726
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | RUSSELL C TEASDALE
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Credential | DMD
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Telephone | 503-235-0555
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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 | D5751
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License Number State | OR
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