Provider Demographics
NPI:1699034082
Name:KEIZER FAMILY DENTAL CARE
Entity Type:Organization
Organization Name:KEIZER FAMILY DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:T
Authorized Official - Last Name:IWAHIRO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-393-2264
Mailing Address - Street 1:4600 RIVER RD N
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-4648
Mailing Address - Country:US
Mailing Address - Phone:503-393-2264
Mailing Address - Fax:503-393-2324
Practice Address - Street 1:4600 RIVER RD N
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4648
Practice Address - Country:US
Practice Address - Phone:503-393-2264
Practice Address - Fax:503-393-2324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD71211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty