Provider Demographics
NPI:1992982938
Name:LAURELHURST DENTISTRY LLC
Entity type:Organization
Organization Name:LAURELHURST DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:
Authorized Official - Last Name:FISCHL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-233-3622
Mailing Address - Street 1:2520 E BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1754
Mailing Address - Country:US
Mailing Address - Phone:503-233-3622
Mailing Address - Fax:503-233-5882
Practice Address - Street 1:2520 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1754
Practice Address - Country:US
Practice Address - Phone:503-233-3622
Practice Address - Fax:503-233-5882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8292122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty