Provider Demographics
NPI:1578783601
Name:EMERALD DENTURE CENTER INC
Entity Type:Organization
Organization Name:EMERALD DENTURE CENTER INC
Other - Org Name:RUSTYS DENTURE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT DENTURIST
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:ANSELMO
Authorized Official - Last Name:CACCIVIO
Authorized Official - Suffix:JR
Authorized Official - Credentials:CD LD RDH
Authorized Official - Phone:541-461-2020
Mailing Address - Street 1:905 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404
Mailing Address - Country:US
Mailing Address - Phone:541-461-2020
Mailing Address - Fax:
Practice Address - Street 1:905 RIVER RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404
Practice Address - Country:US
Practice Address - Phone:541-461-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDTDO461580122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR066662OtherADULT & FAMILY SERVICE