Provider Demographics
NPI:1003898073
Name:SANTIAM DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:SANTIAM DENTAL GROUP, LLC
Other - Org Name:OSBORNE DENTISTRY REGISTRY #1356504-97
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:OSBORNE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-451-4300
Mailing Address - Street 1:150 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-2334
Mailing Address - Country:US
Mailing Address - Phone:541-451-4300
Mailing Address - Fax:541-451-4799
Practice Address - Street 1:150 MARKET ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-2334
Practice Address - Country:US
Practice Address - Phone:541-451-4300
Practice Address - Fax:541-451-4799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD73461223G0001X
ORD50831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty