Provider Demographics
NPI:1154746758
Name:NEWBERG KIDS DENTIST LLC
Entity type:Organization
Organization Name:NEWBERG KIDS DENTIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:NAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWPORT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-747-2111
Mailing Address - Street 1:2502 E PORTLAND RD
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-1923
Mailing Address - Country:US
Mailing Address - Phone:503-538-4289
Mailing Address - Fax:503-538-4352
Practice Address - Street 1:2502 E PORTLAND RD
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-1923
Practice Address - Country:US
Practice Address - Phone:503-538-4289
Practice Address - Fax:503-538-4352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-19
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500675923Medicaid