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12596 Se Stark St Plaza 125 Bldg N Portland OR 97233-1056 | |
| (503) 252-9657 | |
| (503) 256-6909 |
| Full Name | |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 12596 Se Stark St, Portland, Oregon |
| Authorized Official Name and Position | Thomas T Pham (PRESIDENT) |
| Authorized Official Contact | 5032529657 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
12596 Se Stark St Plaza 125 Bldg N Portland OR 97233-1056 Ph: (503) 252-9657 | 12596 Se Stark St Plaza 125 Bldg N Portland OR 97233-1056 Ph: (503) 252-9657 |
| NPI Number | 1629279674 |
|---|---|
| Provider Enumeration Date | 05/29/2007 |
| Last Update Date | 08/22/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1629279674 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | D8300 (Oregon) | Primary |
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