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2517 Se 179th Ave Portland OR 97236-1035 | |
| (503) 761-4001 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 2517 Se 179th Ave, Portland, Oregon |
| Authorized Official Name and Position | Ryan Wayne Carpenter (OWNER/PRESIDENT) |
| Authorized Official Contact | 5035390595 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 916 Clackamas OR 97015-0916 Ph: (503) 539-0595 | 2517 Se 179th Ave Portland OR 97236-1035 Ph: (503) 761-4001 |
| NPI Number | 1023559069 |
|---|---|
| Provider Enumeration Date | 03/09/2017 |
| Last Update Date | 03/09/2017 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1023559069 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | D8618 (Oregon) | Primary |
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