Provider Demographics
NPI:1346607363
Name:PEDIATRIC DENTISTRY OF WEST LINN
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF WEST LINN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:KYLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRASMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-235-0313
Mailing Address - Street 1:2020 8TH AVE
Mailing Address - Street 2:SUITE #121
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-4657
Mailing Address - Country:US
Mailing Address - Phone:503-305-6505
Mailing Address - Fax:
Practice Address - Street 1:2020 8TH AVE
Practice Address - Street 2:SUITE #121
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-4657
Practice Address - Country:US
Practice Address - Phone:503-305-6505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty