Provider Demographics
NPI:1255666467
Name:DR. MILLGARD
Entity Type:Organization
Organization Name:DR. MILLGARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:MILLGARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-526-9742
Mailing Address - Street 1:270 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:WA
Mailing Address - Zip Code:99328-1353
Mailing Address - Country:US
Mailing Address - Phone:509-526-9742
Mailing Address - Fax:
Practice Address - Street 1:270 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:WA
Practice Address - Zip Code:99328-1353
Practice Address - Country:US
Practice Address - Phone:509-526-9742
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH 00005586261QD0000X
ORH5723261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORH5723OtherOREGON BOARD OF DENTISTRY
WADH 00005586OtherWASHINGTON STATE HEALTH DEPARTMENT