Provider Demographics
NPI:1558601385
Name:CRISDENTAL EAST SALEM, LLC
Entity Type:Organization
Organization Name:CRISDENTAL EAST SALEM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRATLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-672-2747
Mailing Address - Street 1:3019 NW STEWART PKWY
Mailing Address - Street 2:STE 304, BOX 311
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-1602
Mailing Address - Country:US
Mailing Address - Phone:541-672-2747
Mailing Address - Fax:541-672-2757
Practice Address - Street 1:3545 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1435
Practice Address - Country:US
Practice Address - Phone:541-672-2747
Practice Address - Fax:541-672-2757
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRISDENTAL GROUP, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-14
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty