Provider Demographics
NPI:1194423988
Name:REVOLUTION DENTAL IMPLANT CENTER
Entity type:Organization
Organization Name:REVOLUTION DENTAL IMPLANT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOUTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-777-3333
Mailing Address - Street 1:19017 BEAVERCREEK RD
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-9537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19017 BEAVERCREEK RD
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-9537
Practice Address - Country:US
Practice Address - Phone:503-777-3333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORD9000OtherSTATE LICENSE NUMBER
ORD9000OtherSTATE LICENSE NUMBER