Provider Demographics
NPI:1326454679
Name:CRISDENTAL EAGLE POINT LLC
Entity Type:Organization
Organization Name:CRISDENTAL EAGLE POINT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRATLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-672-2747
Mailing Address - Street 1:1333 W HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2838
Mailing Address - Country:US
Mailing Address - Phone:541-672-2747
Mailing Address - Fax:866-216-6527
Practice Address - Street 1:217 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EAGLE POINT
Practice Address - State:OR
Practice Address - Zip Code:97524-0450
Practice Address - Country:US
Practice Address - Phone:541-672-2747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRISDENTAL GROUP PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty