Provider Demographics
NPI:1902287469
Name:GATEWAY DENTAL SURGERY CENTER
Entity Type:Organization
Organization Name:GATEWAY DENTAL SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-571-8181
Mailing Address - Street 1:10535 NE GLISAN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-4095
Mailing Address - Country:US
Mailing Address - Phone:971-229-8777
Mailing Address - Fax:
Practice Address - Street 1:10535 NE GLISAN ST STE 101
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4095
Practice Address - Country:US
Practice Address - Phone:971-229-8777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL SERVICE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-10
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical