Provider Demographics
NPI:1568786911
Name:WOODBURN DENTAL GROUP, P.C.
Entity Type:Organization
Organization Name:WOODBURN DENTAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-981-1841
Mailing Address - Street 1:1034 N. BOONES FERRY RD.
Mailing Address - Street 2:
Mailing Address - City:WOODBURN
Mailing Address - State:OR
Mailing Address - Zip Code:97071
Mailing Address - Country:US
Mailing Address - Phone:503-982-9428
Mailing Address - Fax:503-982-5048
Practice Address - Street 1:1034 N. BOONES FERRY RD.
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071
Practice Address - Country:US
Practice Address - Phone:503-982-9428
Practice Address - Fax:503-982-5048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD6259122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty