Basic Information
| Provider Information | |||||||||
| NPI: | 1609837574 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OREGON HEALTH & SCIENCE UNIVERSITY | ||||||||
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| OtherOrganizationName: | DIAGNOSTIC LAB OHSU DENTISTRY SCH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10076 | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914100076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055788300 | ||||||||
| FaxNumber: | 8055788950 | ||||||||
| Practice Location | |||||||||
| Address1: | 2730 SW MOODY AVE | ||||||||
| Address2: | SD-PATH | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972015042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034948904 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2006 | ||||||||
| LastUpdateDate: | 08/04/2014 | ||||||||
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| AuthorizedOfficialLastName: | STEWART | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5034948904 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 1223P0106X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Pathology |
ID Information
| ID | Type | State | Issuer | Description | 182769 | 05 | CA | MEDICAID |