Provider Demographics
NPI:1588992317
Name:JOVAN M GVOZDEN DMD MASTER DENTAL CORP
Entity type:Organization
Organization Name:JOVAN M GVOZDEN DMD MASTER DENTAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JOVAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:GVOZDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-853-5284
Mailing Address - Street 1:1441 NW SLOCUM WAY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-9139
Mailing Address - Country:US
Mailing Address - Phone:503-853-5284
Mailing Address - Fax:
Practice Address - Street 1:12661 SE POWELL BLVD
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:503-853-5284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-07
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8856305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization