Provider Demographics
NPI:1124246285
Name:WESTOVER DENTAL CLINIC
Entity type:Organization
Organization Name:WESTOVER DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:BELUSKO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-224-2273
Mailing Address - Street 1:419 NW 23RD AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3470
Mailing Address - Country:US
Mailing Address - Phone:503-224-2273
Mailing Address - Fax:503-224-1176
Practice Address - Street 1:419 NW 23RD AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3470
Practice Address - Country:US
Practice Address - Phone:503-224-2273
Practice Address - Fax:503-224-1176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD5148122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty