Provider Demographics
NPI:1033539663
Name:LANE COMMUNITY COLLEGE DENTAL CLINIC
Entity Type:Organization
Organization Name:LANE COMMUNITY COLLEGE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEAN OF HEALTH PROFESSIONS, LCC
Authorized Official - Prefix:DR
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:BERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:541-463-5618
Mailing Address - Street 1:4000 E 30TH AVE
Mailing Address - Street 2:DIVISION OF HEALTH PROFESSIONS, BUILDING 30
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-0640
Mailing Address - Country:US
Mailing Address - Phone:541-463-5618
Mailing Address - Fax:541-463-4167
Practice Address - Street 1:2460 WILLAMETTE ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97405-3169
Practice Address - Country:US
Practice Address - Phone:541-463-5206
Practice Address - Fax:541-463-4178
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LANE COMMUNITY COLLEGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD52751223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty