Provider Demographics
NPI:1003245606
Name:PONDEROSA DENTAL ARTS, PC
Entity Type:Organization
Organization Name:PONDEROSA DENTAL ARTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:D
Authorized Official - Last Name:BERKNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:506-656-6464
Mailing Address - Street 1:1174 MOLALLA AVE
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-3770
Mailing Address - Country:US
Mailing Address - Phone:503-656-6464
Mailing Address - Fax:503-577-4677
Practice Address - Street 1:1174 MOLALLA AVE
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-3770
Practice Address - Country:US
Practice Address - Phone:503-656-6464
Practice Address - Fax:503-577-4677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9967122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty