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General NPI Number Information
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NPI Number | 1568673283
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Entity Type | Organization
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Legal Business Name | POWELL DENTAL P.C.
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Dates
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Enumeration Date | 05/24/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3435 SE 75TH AVE
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City | PORTLAND
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State | OR
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Zip | 97206-2407
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Country | US
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Telephone | 503-777-5544
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Fax | 503-777-0460
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Provider Business Mailing Address
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Address Line | 3435 SE 75TH AVE
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City | PORTLAND
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State | OR
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Zip | 97206-2407
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Country | US
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Telephone | 503-777-5544
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Fax | 503-777-0460
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Authorized Official
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Title or Position | DENTIST
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Name | RYAN BLAIR
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Credential | D.M.D
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Telephone | 503-777-5544
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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 | 7887
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License Number State | OR
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