Provider Demographics
NPI:1467596528
Name:NORTHWEST DENTAL GROUP, PC-LAPINE
Entity Type:Organization
Organization Name:NORTHWEST DENTAL GROUP, PC-LAPINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:YANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-536-0264
Mailing Address - Street 1:16475 BLUEWOOD PLACE
Mailing Address - Street 2:PO BOX 2999
Mailing Address - City:LAPINE
Mailing Address - State:OR
Mailing Address - Zip Code:97739-2999
Mailing Address - Country:US
Mailing Address - Phone:541-536-0264
Mailing Address - Fax:541-536-0266
Practice Address - Street 1:16475 BLUEWOOD PLACE
Practice Address - Street 2:
Practice Address - City:LAPINE
Practice Address - State:OR
Practice Address - Zip Code:97739-2999
Practice Address - Country:US
Practice Address - Phone:541-536-0264
Practice Address - Fax:541-536-0266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD78231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty