| NPI | 1104173244 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | IAN STUART TYDEMAN Dentist 503-577-3168 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D6896) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D9162) |
| Enumeration Date | 2012-08-08 |
| Last Update Date | 2012-08-08 |