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2824 Ne Wasco St Suite 230 Portland OR 97232-1772 | |
| (503) 954-1372 | |
| (503) 954-1392 |
| Full Name | |
|---|---|
| Speciality | Dentist - Periodontics |
| Location | 2824 Ne Wasco St, Portland, Oregon |
| Authorized Official Name and Position | Laurissa M Champion (OWNER) |
| Authorized Official Contact | 5039541372 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
2824 Ne Wasco St Suite 230 Portland OR 97232-1772 Ph: (503) 954-1372 | 2824 Ne Wasco St Suite 230 Portland OR 97232-1772 Ph: (503) 954-1372 |
| NPI Number | 1063774784 |
|---|---|
| Provider Enumeration Date | 06/08/2012 |
| Last Update Date | 06/08/2012 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1063774784 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223P0300X | Dentist - Periodontics | D8555 (Oregon) | Primary |
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