Provider Demographics
NPI:1689892465
Name:FAMILY DENTAL GROUP OF NEWPORT PC
Entity Type:Organization
Organization Name:FAMILY DENTAL GROUP OF NEWPORT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:BUILDER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-265-4221
Mailing Address - Street 1:123 SE DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365
Mailing Address - Country:US
Mailing Address - Phone:541-265-4221
Mailing Address - Fax:541-574-6552
Practice Address - Street 1:123 SE DOUGLAS ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-4426
Practice Address - Country:US
Practice Address - Phone:541-265-4221
Practice Address - Fax:541-574-6552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty