Provider Demographics
NPI:1477939494
Name:APPLEGATE VALLEY DENTAL, INC.
Entity Type:Organization
Organization Name:APPLEGATE VALLEY DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-855-7920
Mailing Address - Street 1:181 UPPER APPLEGATE RD
Mailing Address - Street 2:SUITE 20
Mailing Address - City:JACKSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97530-9739
Mailing Address - Country:US
Mailing Address - Phone:541-899-7824
Mailing Address - Fax:541-899-7949
Practice Address - Street 1:181 UPPER APPLEGATE RD
Practice Address - Street 2:SUITE 20
Practice Address - City:JACKSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97530-9739
Practice Address - Country:US
Practice Address - Phone:541-899-7824
Practice Address - Fax:541-899-7949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD62621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty