Provider Demographics
NPI:1760741078
Name:CRISDENTAL SALEM L.L.C.
Entity Type:Organization
Organization Name:CRISDENTAL SALEM L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRATLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-672-2747
Mailing Address - Street 1:1333 W HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2838
Mailing Address - Country:US
Mailing Address - Phone:541-672-2747
Mailing Address - Fax:
Practice Address - Street 1:1355 EDGEWATER ST NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-4077
Practice Address - Country:US
Practice Address - Phone:503-588-6960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRISDENTAL P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty