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General NPI Number Information
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NPI Number | 1669759767
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Entity Type | Organization
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Legal Business Name | HERITAGE DENTAL
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Dates
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Enumeration Date | 11/03/2011
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Last Update Date | 07/11/2013
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Provider Practice Location Address
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Address Line | 4511 SE HAWTHORNE BLVD SUITE 101
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City | PORTLAND
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State | OR
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Zip | 97215-3195
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Country | US
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Telephone | 503-231-8228
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Fax | 503-231-5634
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Provider Business Mailing Address
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Address Line | 4511 SE HAWTHORNE BLVD SUITE 101
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City | PORTLAND
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State | OR
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Zip | 97215-3195
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Country | US
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Telephone | 503-231-8228
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Fax | 503-231-5634
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. DENISE JEAN CRANE
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Credential |
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Telephone | 503-231-8228
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 9096
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 5651
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License Number State | OR
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