Provider Demographics
NPI:1790225399
Name:CHILDRENS DENTISTRY
Entity Type:Organization
Organization Name:CHILDRENS DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRYSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-467-5100
Mailing Address - Street 1:515 W IDAHO AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-2348
Mailing Address - Country:US
Mailing Address - Phone:541-709-5500
Mailing Address - Fax:208-467-5199
Practice Address - Street 1:515 W IDAHO AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2348
Practice Address - Country:US
Practice Address - Phone:541-709-5500
Practice Address - Fax:208-467-5199
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDRENS DENTISTRY OF IDAHO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD103491223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty