| Mountainside Family Dentistry Llc | |
|
3740 Se 122nd Ave Portland OR 97236-3405 | |
| (503) 762-2525 | |
| (503) 762-4872 |
| Full Name | Mountainside Family Dentistry Llc |
|---|---|
| Speciality | Dentist |
| Location | 3740 Se 122nd Ave, Portland, Oregon |
| Authorized Official Name and Position | Derek W. Conklin (DENTIST/OWNER/ PRESIDENT) |
| Authorized Official Contact | 5037622525 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Mountainside Family Dentistry Llc 3740 Se 122nd Ave Portland OR 97236-3405 Ph: (503) 762-2525 | Mountainside Family Dentistry Llc 3740 Se 122nd Ave Portland OR 97236-3405 Ph: (503) 762-2525 |
| NPI Number | 1295080836 |
|---|---|
| Provider Enumeration Date | 07/19/2012 |
| Last Update Date | 07/19/2012 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1295080836 | NPI | - | NPPES |
| 243185 | Medicaid | OR |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | D8325 (Oregon) | Primary |
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