Provider Demographics
NPI:1992307367
Name:FIRST IMPRESSIONS DENTURE STUDIO
Entity type:Organization
Organization Name:FIRST IMPRESSIONS DENTURE STUDIO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-230-0207
Mailing Address - Street 1:200 NE 20TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-3094
Mailing Address - Country:US
Mailing Address - Phone:503-230-0207
Mailing Address - Fax:503-230-0208
Practice Address - Street 1:200 NE 20TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3094
Practice Address - Country:US
Practice Address - Phone:503-230-0207
Practice Address - Fax:503-230-0208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-11
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty