Provider Demographics
NPI:1033349816
Name:SOUTH UMPQUA FAMILY DENTAL
Entity Type:Organization
Organization Name:SOUTH UMPQUA FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNELIUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-874-3126
Mailing Address - Street 1:150 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:RIDDLE
Mailing Address - State:OR
Mailing Address - Zip Code:97469
Mailing Address - Country:US
Mailing Address - Phone:541-874-3126
Mailing Address - Fax:541-874-3259
Practice Address - Street 1:150 MAIN STREET
Practice Address - Street 2:
Practice Address - City:RIDDLE
Practice Address - State:OR
Practice Address - Zip Code:97469
Practice Address - Country:US
Practice Address - Phone:541-874-3126
Practice Address - Fax:541-874-3259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-15
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD92811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty