Provider Demographics
NPI:1104156959
Name:SUNNYSIDE DENTISTRY FOR CHILDREN, P.C.
Entity type:Organization
Organization Name:SUNNYSIDE DENTISTRY FOR CHILDREN, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:DOYLE, JR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-855-5100
Mailing Address - Street 1:11411 SE SUNNYSIDE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5713
Mailing Address - Country:US
Mailing Address - Phone:503-855-5100
Mailing Address - Fax:503-826-5196
Practice Address - Street 1:11411 SE SUNNYSIDE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5745
Practice Address - Country:US
Practice Address - Phone:503-855-5100
Practice Address - Fax:503-826-5196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-29
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD64901223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR005996Medicaid