Provider Demographics
NPI:1053857433
Name:BETHANY FAMILY DENTAL PC
Entity type:Organization
Organization Name:BETHANY FAMILY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WELIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-617-7384
Mailing Address - Street 1:4732 NW BETHANY BLVD
Mailing Address - Street 2:STE G-2
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-9410
Mailing Address - Country:US
Mailing Address - Phone:503-617-7384
Mailing Address - Fax:
Practice Address - Street 1:4732 NW BETHANY BLVD
Practice Address - Street 2:STE G-2
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-9410
Practice Address - Country:US
Practice Address - Phone:503-617-7384
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD68571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty