Provider Demographics
NPI:1134308810
Name:OREGON PIP DENTAL GROUP, PC
Entity Type:Organization
Organization Name:OREGON PIP DENTAL GROUP, PC
Other - Org Name:ADVANCED PEDIATRIC DENTISTY ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:REGIONAL OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELLISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:RENNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-667-4145
Mailing Address - Street 1:1060 W ELM AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-2723
Mailing Address - Country:US
Mailing Address - Phone:541-289-5433
Mailing Address - Fax:
Practice Address - Street 1:1060 W ELM AVE STE 115
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-2723
Practice Address - Country:US
Practice Address - Phone:541-289-5433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD76661223P0221X
ORD90441223P0221X
ORD92461223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty