Provider Demographics
NPI:1134661606
Name:ACORN DENTISTRY FOR KIDS - KEIZER, LLC
Entity Type:Organization
Organization Name:ACORN DENTISTRY FOR KIDS - KEIZER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-852-0809
Mailing Address - Street 1:4817 RIVER RD N
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-4537
Mailing Address - Country:US
Mailing Address - Phone:360-852-0809
Mailing Address - Fax:
Practice Address - Street 1:4817 RIVER RD N
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4537
Practice Address - Country:US
Practice Address - Phone:360-852-0809
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACORN DENTISTRY FOR KIDS - KEIZER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9577261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental