Provider Demographics
NPI:1235334012
Name:GLEN CREEK DENTAL LLC
Entity Type:Organization
Organization Name:GLEN CREEK DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-581-1142
Mailing Address - Street 1:470 GLEN CREEK RD NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3060
Mailing Address - Country:US
Mailing Address - Phone:503-581-1142
Mailing Address - Fax:503-581-4809
Practice Address - Street 1:470 GLEN CREEK RD NW
Practice Address - Street 2:SUITE 100
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-3060
Practice Address - Country:US
Practice Address - Phone:503-581-1142
Practice Address - Fax:503-581-4809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1710965611OtherINDIVIDUAL