Provider Demographics
NPI:1689292781
Name:PACIFIC NORTHWEST DENTAL, LLC
Entity type:Organization
Organization Name:PACIFIC NORTHWEST DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:971-998-3000
Mailing Address - Street 1:11263 SW SPRINGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-3320
Mailing Address - Country:US
Mailing Address - Phone:971-998-3000
Mailing Address - Fax:
Practice Address - Street 1:12725 SW 2ND ST
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2708
Practice Address - Country:US
Practice Address - Phone:503-644-1953
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental