Provider Demographics
NPI:1619230174
Name:MEDFORD DENTAL CLINIC, LLC
Entity Type:Organization
Organization Name:MEDFORD DENTAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:CRAMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-357-4500
Mailing Address - Street 1:3551 E BARNETT RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7037
Mailing Address - Country:US
Mailing Address - Phone:541-772-5755
Mailing Address - Fax:
Practice Address - Street 1:3551 E BARNETT RD STE 101
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7037
Practice Address - Country:US
Practice Address - Phone:541-772-5755
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 10599122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty