Provider Demographics
NPI:1306183074
Name:POWELL DENTAL SPECIALTIES
Entity type:Organization
Organization Name:POWELL DENTAL SPECIALTIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENDODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:GABY
Authorized Official - Last Name:BASSILI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-432-3997
Mailing Address - Street 1:12661 SE POWELL BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-3400
Mailing Address - Country:US
Mailing Address - Phone:503-760-1880
Mailing Address - Fax:503-775-6849
Practice Address - Street 1:12661 SE POWELL BLVD STE D
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-3400
Practice Address - Country:US
Practice Address - Phone:503-760-1880
Practice Address - Fax:503-775-6849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD77991223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty