Provider Demographics
NPI:1760582985
Name:MID-VALLEY DENTAL OF PHILOMATH
Entity Type:Organization
Organization Name:MID-VALLEY DENTAL OF PHILOMATH
Other - Org Name:MID-VALLEY DENTAL ARTS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-928-2301
Mailing Address - Street 1:2811 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PHILOMATH
Mailing Address - State:OR
Mailing Address - Zip Code:97370
Mailing Address - Country:US
Mailing Address - Phone:541-929-5227
Mailing Address - Fax:541-929-7649
Practice Address - Street 1:2811 MAIN ST
Practice Address - Street 2:
Practice Address - City:PHILOMATH
Practice Address - State:OR
Practice Address - Zip Code:97370
Practice Address - Country:US
Practice Address - Phone:541-929-5227
Practice Address - Fax:541-929-7649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7915122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty