Provider Demographics
NPI:1447848023
Name:PORTLAND ORTHODONTIC GROUP, LLC
Entity type:Organization
Organization Name:PORTLAND ORTHODONTIC GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER/ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:CROWE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-289-1992
Mailing Address - Street 1:3332 N LOMBARD ST STE B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-1258
Mailing Address - Country:US
Mailing Address - Phone:503-289-1992
Mailing Address - Fax:
Practice Address - Street 1:3332 N LOMBARD ST STE B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-1258
Practice Address - Country:US
Practice Address - Phone:503-289-1992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PORTLAND ORTHODONTIC GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty