Provider Demographics
NPI:1437643616
Name:IDYLWOOD DENTAL LLC
Entity Type:Organization
Organization Name:IDYLWOOD DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:
Authorized Official - Last Name:MERZENICH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-315-2500
Mailing Address - Street 1:PO BOX 3000
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-8001
Mailing Address - Country:US
Mailing Address - Phone:800-544-2345
Mailing Address - Fax:503-315-7227
Practice Address - Street 1:4392 LIBERTY ROAD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-6171
Practice Address - Country:US
Practice Address - Phone:503-315-2500
Practice Address - Fax:503-315-7227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR40631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty