Provider Demographics
NPI:1558549899
Name:COLUMBIA RIVER DENTAL, P.C.
Entity Type:Organization
Organization Name:COLUMBIA RIVER DENTAL, P.C.
Other - Org Name:PINE DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PAYOR RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:DARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-916-8143
Mailing Address - Street 1:210 INTERSTATE NORTH PKWY SE STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-2233
Mailing Address - Country:US
Mailing Address - Phone:770-916-8143
Mailing Address - Fax:770-858-0657
Practice Address - Street 1:1531 MARYLAND AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-7604
Practice Address - Country:US
Practice Address - Phone:770-916-5028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-08
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty