Provider Demographics
NPI:1609043157
Name:EASTERN OREGON DENTAL CLINIC LLC
Entity Type:Organization
Organization Name:EASTERN OREGON DENTAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:N
Authorized Official - Last Name:DAHLE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-881-1794
Mailing Address - Street 1:478 SW 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-3202
Mailing Address - Country:US
Mailing Address - Phone:541-881-1794
Mailing Address - Fax:541-889-2904
Practice Address - Street 1:475 SW 12TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-3201
Practice Address - Country:US
Practice Address - Phone:541-881-1794
Practice Address - Fax:541-889-2904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9048122300000X, 1223E0200X, 1223G0001X, 1223P0300X, 1223S0112X
ORD6574122300000X, 1223E0200X, 1223G0001X, 1223P0300X, 1223S0112X
ORD7219122300000X, 1223E0200X, 1223G0001X, 1223P0300X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty