Provider Demographics
NPI:1700029709
Name:MID-VALLEY DENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MID-VALLEY DENTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-928-2301
Mailing Address - Street 1:2825 WILLETTA ST SW
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-3846
Mailing Address - Country:US
Mailing Address - Phone:541-928-2301
Mailing Address - Fax:541-928-8493
Practice Address - Street 1:2825 WILLETTA ST SW
Practice Address - Street 2:SUITE A
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-3846
Practice Address - Country:US
Practice Address - Phone:541-928-2301
Practice Address - Fax:541-928-8493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD79151223G0001X
ORD86731223G0001X
ORD90841223G0001X
ORD91071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty