Provider Demographics
NPI:1497823546
Name:MILL CREEK DENTAL, INC.
Entity Type:Organization
Organization Name:MILL CREEK DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:WILLLIAM
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-769-9699
Mailing Address - Street 1:521 N 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-1703
Mailing Address - Country:US
Mailing Address - Phone:503-769-9699
Mailing Address - Fax:503-769-8599
Practice Address - Street 1:521 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-1703
Practice Address - Country:US
Practice Address - Phone:503-769-9699
Practice Address - Fax:503-769-8599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD68541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty