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4707 Ne 102nd Ave Ste A Portland OR 97220-3393 | |
| (971) 867-2956 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Clinic/center - Dental |
| Location | 4707 Ne 102nd Ave Ste A, Portland, Oregon |
| Authorized Official Name and Position | Pavel Ivanovich Saranchuk (MANAGER/AUTHORIZED SIGNER) |
| Authorized Official Contact | 5039024300 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
4707 Ne 102nd Ave Ste A Portland OR 97220-3393 Ph: (971) 867-2956 | 4707 Ne 102nd Ave Ste A Portland OR 97220-3393 Ph: (971) 867-2956 |
| NPI Number | 1528546330 |
|---|---|
| Provider Enumeration Date | 08/02/2018 |
| Last Update Date | 08/02/2018 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1528546330 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QD0000X | Clinic/center - Dental | D10185 (Oregon) | Primary |
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