Provider Demographics
NPI:1700819596
Name:EAST MAIN DENTAL CENTER, LLP
Entity Type:Organization
Organization Name:EAST MAIN DENTAL CENTER, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SOWLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-773-3422
Mailing Address - Street 1:1123 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7434
Mailing Address - Country:US
Mailing Address - Phone:541-773-3422
Mailing Address - Fax:541-779-2250
Practice Address - Street 1:1123 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7434
Practice Address - Country:US
Practice Address - Phone:541-773-3422
Practice Address - Fax:541-779-2250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR55631223G0001X
OR60251223G0001X
ORD67351223G0001X
ORD65711223G0001X
ORD77891223G0001X
ORD87651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR04407-3OtherOMAP PROVIDER NUMBER
OR22707-2OtherOMAP PROVIDER NUMBER
OR28445-5OtherOMAP PROVIDER NUMBER
OR08594-9OtherOMAP PROVIDER NUMBER
OR21816-4OtherOMAP PROVIDER