Provider Demographics
NPI:1134472723
Name:BOONE'S LANDING DENTAL CENTER, LLC
Entity Type:Organization
Organization Name:BOONE'S LANDING DENTAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-682-3743
Mailing Address - Street 1:29970 SW TOWN CENTER LOOP W
Mailing Address - Street 2:SUITE D
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-7429
Mailing Address - Country:US
Mailing Address - Phone:503-682-3743
Mailing Address - Fax:503-682-1279
Practice Address - Street 1:30485 SW BOONES FERRY RD
Practice Address - Street 2:SUITE 203
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-7845
Practice Address - Country:US
Practice Address - Phone:503-682-3743
Practice Address - Fax:503-682-1279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD6595122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty