Provider Demographics
NPI:1265815799
Name:ROGUE VALLEY FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:ROGUE VALLEY FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUISNESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-269-5353
Mailing Address - Street 1:1250 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2538
Mailing Address - Country:US
Mailing Address - Phone:541-269-5353
Mailing Address - Fax:541-266-0933
Practice Address - Street 1:1873 WILLIAMS HWY STE 1A
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5843
Practice Address - Country:US
Practice Address - Phone:541-479-5505
Practice Address - Fax:541-479-7891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD96191223G0001X
ORD93991223G0001X
ORD96041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty