Sam Seoho Bae, M.D., D.D.S.
Individual provider Active NPI Oral & Maxillofacial Surgery (D.M.D.) · Tualatin, OR
NPI 1124381629 · NPPES record last updated Jun 29, 2019
Key facts
- NPI
- 1124381629
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Oral & Maxillofacial Surgery (D.M.D.) 204E00000X
- License
- MD191912 (OR)
- Practice address
- 6464 SW Borland Rd Ste D3
Tualatin, OR 97062 - Phone
- (503) 692-5654
- NPI assigned
- Jun 19, 2012
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in OR
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20250808001315 | OR | Order and Referring Only - Oral Surgery |
8628384682 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2901020742 | MI | MD | Oral & Maxillofacial Surgery (D.M.D.) |
| 4301109828 | MI | MD | Oral & Maxillofacial Surgery (D.M.D.) |
| MD191912 | OR | MD | Oral & Maxillofacial Surgery (D.M.D.) |
| 33845 | TX | MD | Oral & Maxillofacial Surgery (D.M.D.) |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Three Rivers Oral and Facial Surgery LLC | Oral & Maxillofacial Surgery | Past |
Accepting new patients |
Interoperability endpoints
- sam.bae@direct.myhealthep.org
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Oral & Maxillofacial Surgery (D.M.D.) | 204E00000X | 33845 | TX | |
| Oral & Maxillofacial Surgery (D.M.D.) | 204E00000X | 2901020742 | MI | |
| Oral & Maxillofacial Surgery (D.M.D.) |
204E00000X | R6146 | TX | |
| Oral & Maxillofacial Surgery (D.M.D.) | 204E00000X | 4301109828 | MI | |
| Oral & Maxillofacial Surgery (D.M.D.) | 204E00000X | MD191912 | OR | Yes |
Addresses
Primary practice location
6464 SW Borland Rd Ste D3
Tualatin, OR 97062
Mailing address
6464 SW Borland Rd Ste D3
Tualatin, OR 97062-8861
Phone (503) 692-5654
Other providers in Tualatin, OR
- Autonomic Innovations, LLC
- Wassim Ayoub
- Baarspul Physical Therapy and Sports Medicine, LLC
- Dilip Sankar Babu
- Serena Badgley
- Christine A Baird
- Leah Baird
- Kari A. Baker
- Margaret Elizabeth Baker
- Rick Baldwin
All providers in Tualatin, OR · Oral & Maxillofacial Surgery (D.M.D.) in Oregon
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 29, 2019. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.