Provider Demographics
NPI:1518296193
Name:OAK PARK FAMILY DENTAL CARE
Entity Type:Organization
Organization Name:OAK PARK FAMILY DENTAL CARE
Other - Org Name:OAK PARK FAMILY DENTAL CARE-HIGH ST
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:KETCHUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-588-7800
Mailing Address - Street 1:760 HIGH ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2440
Mailing Address - Country:US
Mailing Address - Phone:503-588-7800
Mailing Address - Fax:503-391-0762
Practice Address - Street 1:760 HIGH ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2440
Practice Address - Country:US
Practice Address - Phone:503-588-7800
Practice Address - Fax:503-391-0762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD70201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty