Provider Demographics
NPI:1114261104
Name:SUMMIT FAMILY DENTAL CARE PC
Entity Type:Organization
Organization Name:SUMMIT FAMILY DENTAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KECK-ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-779-2634
Mailing Address - Street 1:906 ROYAL CT
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6139
Mailing Address - Country:US
Mailing Address - Phone:541-779-2636
Mailing Address - Fax:541-779-3282
Practice Address - Street 1:906 ROYAL CT
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6139
Practice Address - Country:US
Practice Address - Phone:541-779-2636
Practice Address - Fax:541-779-3282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD91391223G0001X
ORD91581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty