Provider Demographics
NPI:1679897292
Name:PEDIATRIC DENTAL CLINIC
Entity type:Organization
Organization Name:PEDIATRIC DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:BUM-JOON
Authorized Official - Last Name:KANG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-612-1897
Mailing Address - Street 1:19255 SW 65TH AVE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-7451
Mailing Address - Country:US
Mailing Address - Phone:503-612-1897
Mailing Address - Fax:503-612-1899
Practice Address - Street 1:19255 SW 65TH AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7451
Practice Address - Country:US
Practice Address - Phone:503-612-1897
Practice Address - Fax:503-612-1899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty