Provider Demographics
NPI:1114660800
Name:MCKENZIE RIVER DENTAL, LLC
Entity Type:Organization
Organization Name:MCKENZIE RIVER DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-736-0044
Mailing Address - Street 1:244 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-4602
Mailing Address - Country:US
Mailing Address - Phone:541-736-0044
Mailing Address - Fax:541-654-4552
Practice Address - Street 1:244 6TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4602
Practice Address - Country:US
Practice Address - Phone:541-736-0044
Practice Address - Fax:541-654-4552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty