Provider Demographics
NPI:1790169217
Name:ORTHO COUNTRY ORTHODONTICS LLC
Entity Type:Organization
Organization Name:ORTHO COUNTRY ORTHODONTICS LLC
Other - Org Name:ORTHO COUNTRY ORTHO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-472-8320
Mailing Address - Street 1:1300 NE ALPHA DR
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-9711
Mailing Address - Country:US
Mailing Address - Phone:512-947-8916
Mailing Address - Fax:
Practice Address - Street 1:1300 NE ALPHA DR
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-9711
Practice Address - Country:US
Practice Address - Phone:512-947-8916
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty