NPI 1265067615

Ivan John Konkin

Practitioner Denturist Portland, OR

Practice location

Address: 12661 SE Powell Blvd STE C, Portland, OR 97236-3400
Phone: (503) 655-4007

Registered specialties

Denturist Primary

Dental Providers Taxonomy 122400000X Licence DT-DO-10204635 (OR)

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Registry record

NPI: 1265067615
Entity type: Individual
Sex (as registered): Male
NPI issued: 5 Mar 2020
Record last updated: 6 Mar 2020

Reproduced from NPPES, the federal provider registry. The date above is when the provider last updated their own entry, not when we fetched it - a record can be years old and still current in the registry.