Provider Demographics
NPI:1659675338
Name:SOUTH UMPQUA FAMILY DENTAL PC
Entity Type:Organization
Organization Name:SOUTH UMPQUA FAMILY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:D
Authorized Official - Last Name:CORNELIUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-874-3126
Mailing Address - Street 1:PO BOX 107
Mailing Address - Street 2:
Mailing Address - City:RIDDLE
Mailing Address - State:OR
Mailing Address - Zip Code:97469-0107
Mailing Address - Country:US
Mailing Address - Phone:541-874-3126
Mailing Address - Fax:541-874-3259
Practice Address - Street 1:150 MAIN STREET
Practice Address - Street 2:
Practice Address - City:RIDDLE
Practice Address - State:OR
Practice Address - Zip Code:97469-0107
Practice Address - Country:US
Practice Address - Phone:541-874-3126
Practice Address - Fax:541-874-3259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9281122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty