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General NPI Number Information
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NPI Number | 1639604689
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Entity Type | Organization
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Legal Business Name | PORTLAND DENTAL ANESTHESIA
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Dates
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Enumeration Date | 04/27/2017
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Last Update Date | 04/27/2017
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Provider Practice Location Address
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Address Line | 21370 SW LANGER FARMS PKWY #142
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City | SHERWOOD
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State | OR
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Zip | 97140-9137
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Country | US
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Telephone | 503-858-4880
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Fax | 503-914-6685
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Provider Business Mailing Address
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Address Line | 21370 SW LANGER FARMS PKWY #142
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City | SHERWOOD
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State | OR
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Zip | 97140-9137
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Country | US
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Telephone | 503-858-4880
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Fax | 503-914-6685
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Authorized Official
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Title or Position | OWNER
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Name | DR. RYAN T ALLRED
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Credential | DMD
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Telephone | 503-858-4880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223D0004X
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Taxonomy Name | Dental Anesthesiology
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License Number | D9387
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License Number State | OR
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