Individual
IVAN JOHN KONKIN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
12661 SE POWELL BLVD STE C, PORTLAND, OR 97236-3400
(503) 655-4007
Mailing address
12661 SE POWELL BLVD STE C, PORTLAND, OR 97236-3400
(503) 655-4007
Taxonomy
Speciality
Code
Description
License number
State
122400000X
Denturist
Primary
DT-DO-10204635
OR
Other
Enumeration date
03/05/2020
Last updated
03/06/2020
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