Provider Demographics
NPI:1427574136
Name:SHASTA FAMILY DENTAL
Entity Type:Organization
Organization Name:SHASTA FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MINDY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-884-5474
Mailing Address - Street 1:2504 SHASTA WAY
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-4356
Mailing Address - Country:US
Mailing Address - Phone:541-884-5474
Mailing Address - Fax:541-882-1461
Practice Address - Street 1:2504 SHASTA WAY
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-4356
Practice Address - Country:US
Practice Address - Phone:541-884-5474
Practice Address - Fax:541-882-1461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10646261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental