Provider Demographics
NPI:1275924227
Name:CORVALLIS CHILDREN'S DENTISTRY PC
Entity Type:Organization
Organization Name:CORVALLIS CHILDREN'S DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KALE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-243-8988
Mailing Address - Street 1:2350 NW CENTURY DR
Mailing Address - Street 2:STE 210
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3495
Mailing Address - Country:US
Mailing Address - Phone:541-243-8988
Mailing Address - Fax:541-243-8990
Practice Address - Street 1:2350 NW CENTURY DR
Practice Address - Street 2:STE 210
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3495
Practice Address - Country:US
Practice Address - Phone:541-243-8988
Practice Address - Fax:541-243-8990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty