Provider Demographics
NPI:1053886580
Name:SANDY DENTAL PDX
Entity type:Organization
Organization Name:SANDY DENTAL PDX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHONG
Authorized Official - Middle Name:THANH
Authorized Official - Last Name:BUI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-473-7284
Mailing Address - Street 1:7836 NE SANDY BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213
Mailing Address - Country:US
Mailing Address - Phone:503-288-3107
Mailing Address - Fax:
Practice Address - Street 1:7836 NE SANDY BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213
Practice Address - Country:US
Practice Address - Phone:503-288-3107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty