Provider Demographics
NPI:1255762449
Name:TUALATIN PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:TUALATIN PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:S
Authorized Official - Last Name:YARBOROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-692-3747
Mailing Address - Street 1:18803 SW BOONES FERRY RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8412
Mailing Address - Country:US
Mailing Address - Phone:503-692-3747
Mailing Address - Fax:503-612-6948
Practice Address - Street 1:18803 SW BOONES FERRY RD
Practice Address - Street 2:SUITE 5
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8412
Practice Address - Country:US
Practice Address - Phone:503-692-3747
Practice Address - Fax:503-612-6948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9222261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental