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Organization
ICP TELEDENTISTRY
Active
Organization
ICP TELEDENTISTRY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. CHANDAN SHARMA (HOD)
(425) 494-0883
Entity
Organization
Contact information
Practice address
3439 SE HAWTHORNE BLVD # 906, PORTLAND, OR 97214-5048
(425) 494-0883
Mailing address
3439 SE HAWTHORNE BLVD # 906, PORTLAND, OR 97214-5048
Taxonomy
Speciality
Code
Description
License number
State
1223D0001X
Public Health Dentistry
Primary
—
—
124Q00000X
Dental Hygienist
—
—
125J00000X
Dental Therapist
—
—
126800000X
Dental Assistant
—
—
261QD0000X
Dental Clinic/Center
—
—
261QS0112X
Oral and Maxillofacial Surgery Clinic/Center
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
006880293
DL
LA
Enumeration date
04/18/2022
Last updated
04/18/2022
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