Provider Demographics
NPI:1619180007
Name:PACIFIC DENTAL INSTITUTE
Entity type:Organization
Organization Name:PACIFIC DENTAL INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SORENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, PHD
Authorized Official - Phone:503-639-5136
Mailing Address - Street 1:12750 SW 68TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223
Mailing Address - Country:US
Mailing Address - Phone:503-639-5136
Mailing Address - Fax:503-620-0187
Practice Address - Street 1:12750 SW 68TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-8596
Practice Address - Country:US
Practice Address - Phone:503-639-5136
Practice Address - Fax:503-620-0187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD71651223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty