Provider Demographics
NPI:1366755613
Name:ALL CITY DENTURE CLINIC PC
Entity type:Organization
Organization Name:ALL CITY DENTURE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMPLOYER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DT-DO
Authorized Official - Phone:503-760-8409
Mailing Address - Street 1:12661 SE POWELL BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-3400
Mailing Address - Country:US
Mailing Address - Phone:503-760-8409
Mailing Address - Fax:503-760-8577
Practice Address - Street 1:12661 SE POWELL BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-3400
Practice Address - Country:US
Practice Address - Phone:503-760-8409
Practice Address - Fax:503-760-8577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDTDO949472292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory