Organization
MOUNTAINSIDE FAMILY DENTISTRY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DEREK W. CONKLIN DMD (DENTIST/OWNER/ PRESIDENT)
(503) 762-2525
Entity
Organization
Contact information
Practice address
3740 SE 122ND AVE, PORTLAND, OR 97236-3405
(503) 762-2525
(503) 762-4872
Mailing address
3740 SE 122ND AVE, PORTLAND, OR 97236-3405
(503) 762-2525
(503) 762-4872
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
D8325
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
243185
—
OR
Enumeration date
07/19/2012
Last updated
07/19/2012
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