Provider Demographics
NPI:1104198829
Name:NW DENTAL CLINIC, LLC
Entity Type:Organization
Organization Name:NW DENTAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PUFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-829-9731
Mailing Address - Street 1:PO BOX 657
Mailing Address - Street 2:
Mailing Address - City:MOLALLA
Mailing Address - State:OR
Mailing Address - Zip Code:97038-0657
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 E 2ND ST
Practice Address - Street 2:
Practice Address - City:MOLALLA
Practice Address - State:OR
Practice Address - Zip Code:97038-9195
Practice Address - Country:US
Practice Address - Phone:503-829-9731
Practice Address - Fax:503-829-8626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9476122300000X
ORD9607122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty