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General NPI Number Information
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NPI Number | 1639504715
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Entity Type | Organization
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Legal Business Name | TIMBER DENTAL LLC
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Dates
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Enumeration Date | 09/09/2013
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Last Update Date | 09/09/2013
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Provider Practice Location Address
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Address Line | 3500 NE MLK
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City | PORTLAND
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State | OR
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Zip | 97212-2093
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Country | US
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Telephone | 971-506-3407
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Fax |
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Provider Business Mailing Address
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Address Line | 5400 NE RODNEY AVE
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City | PORTLAND
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State | OR
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Zip | 97211-2642
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Country | US
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Telephone | 971-506-3407
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Fax |
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Authorized Official
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Title or Position | DENTIST OWNER
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Name | DR. MATTHEW RYAN KATHAN
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Credential | DDS
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Telephone | 971-506-3407
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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 | D9561
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License Number State | OR
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