MEDICARE: GLISAN DENTAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1316178734
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLISAN DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	7990 NE GLISAN ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97213-7040
Country	:	US
Telephone Number	:	503-208-2220
Fax Number	:

Provider Business Practice Location Address
First Line	:	7990 NE GLISAN ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97213-7040
Country	:	US
Telephone Number	:	503-208-2220
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. TAN BA PHAM
Credential	:	DMD
Telephone Number	:	503-208-2220

Provider Enumeration Date	:	08/03/2009
Last Update Date	:	08/03/2009

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Directions to “GLISAN DENTAL CORPORATION ” Practice Location

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