Provider Demographics
NPI:1114568029
Name:SIGNATURE OREGON DENTAL PARTNERS PC
Entity Type:Organization
Organization Name:SIGNATURE OREGON DENTAL PARTNERS PC
Other - Org Name:HORACEK DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF INTEGRATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-234-8490
Mailing Address - Street 1:410 N 44TH ST STE 290
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-7622
Mailing Address - Country:US
Mailing Address - Phone:480-626-4154
Mailing Address - Fax:
Practice Address - Street 1:11815 SW KING JAMES PL STE 10
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-2479
Practice Address - Country:US
Practice Address - Phone:503-433-8256
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SIGNATURE DENTAL PARTNERS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-01
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental