Provider Demographics
NPI:1497190821
Name:SOUTH LANE CHILDREN'S DENTAL CLINIC
Entity Type:Organization
Organization Name:SOUTH LANE CHILDREN'S DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL CARE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:EFDA
Authorized Official - Phone:541-520-7137
Mailing Address - Street 1:1275 S RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-3906
Mailing Address - Country:US
Mailing Address - Phone:541-520-7137
Mailing Address - Fax:
Practice Address - Street 1:1275 S RIVER RD
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-3906
Practice Address - Country:US
Practice Address - Phone:541-520-7137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH LANE SCHOOL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable