Provider Demographics
NPI:1376889311
Name:MICHAEL B DESJARDIN DENTISTY, P.C.
Entity Type:Organization
Organization Name:MICHAEL B DESJARDIN DENTISTY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:DESJARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-575-2725
Mailing Address - Street 1:208 NW CANTON ST
Mailing Address - Street 2:
Mailing Address - City:JOHN DAY
Mailing Address - State:OR
Mailing Address - Zip Code:97845-1145
Mailing Address - Country:US
Mailing Address - Phone:541-575-2725
Mailing Address - Fax:541-575-2635
Practice Address - Street 1:208 NW CANTON ST
Practice Address - Street 2:
Practice Address - City:JOHN DAY
Practice Address - State:OR
Practice Address - Zip Code:97845-1145
Practice Address - Country:US
Practice Address - Phone:541-575-2725
Practice Address - Fax:541-575-2635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD61631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty