38D2059825 CLIA NUMBER - GLISAN DENTAL OFFICE

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Laboratory Demographics

CLIA Number: 38D2059825

Facility Name: GLISAN DENTAL OFFICE

Facility Address:
10102 NE GLISAN AVE
PORTLAND, OR
ZIP 97220
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Facility Phone Number: 503 257-5959

Facility Type: Practitioner Other

Certificate Type: Waiver

NPI Number: 1073065207

Taxonomy: 1223G0001X - Dentist
A general dentist is the primary dental care provider for patients of all ages. The general dentist is responsible for the diagnosis, treatment, management and overall coordination of services related to patients' oral health needs.

CLIA Record

Field Name	Field Value
CLIA Number	38D2059825
LAB Type	Practitioner Other
Facility Name	GLISAN DENTAL OFFICE
Street	10102 NE GLISAN AVE
City	PORTLAND
State	OR
ZIP	97220
Phone	503 257-5959
CertificateType	4
CertificateEffectiveDate	5/31/2023
CertificateExpirationDate	5/30/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024