Provider Demographics
NPI:1184831083
Name:PEDIATRIC DENTISTRY OF SALEM LLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF SALEM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WESTON
Authorized Official - Middle Name:WILLARD
Authorized Official - Last Name:HERINGER
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-364-7545
Mailing Address - Street 1:2020 COMMERCIAL ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-5208
Mailing Address - Country:US
Mailing Address - Phone:503-364-7545
Mailing Address - Fax:503-540-7911
Practice Address - Street 1:2020 COMMERCIAL ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-5208
Practice Address - Country:US
Practice Address - Phone:503-364-7545
Practice Address - Fax:503-540-7911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR77031223P0221X
OR46311223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR087163Medicaid
OR233143Medicaid
OR1223PO221XOtherTAXONOMY CODE
OR087163Medicaid