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General NPI Number Information
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NPI Number | 1598223919
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Entity Type | Organization
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Legal Business Name | PORTLAND MODERN DENTISTRY, PC
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Dates
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Enumeration Date | 03/05/2019
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Last Update Date | 03/09/2022
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Provider Practice Location Address
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Address Line | 5175 NE MARTIN LUTHER KING BLVD STE 110
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City | PORTLAND
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State | OR
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Zip | 97211-3233
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Country | US
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Telephone | 503-406-1108
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 920050
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City | DALLAS
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State | TX
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Zip | 75392-0050
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Country | US
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Telephone | 714-845-8500
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Fax |
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Authorized Official
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Title or Position | OWNER DENTIST
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Name | DR. AUSTIN TODD
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Credential | DDS
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Telephone | 714-845-8500
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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 |
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License Number State |
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