Provider Demographics
NPI:1790239697
Name:CRISDENTAL GRANTS PASS LLC
Entity Type:Organization
Organization Name:CRISDENTAL GRANTS PASS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
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:541-492-1687
Mailing Address - Street 1:PO BOX 1405
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0338
Mailing Address - Country:US
Mailing Address - Phone:541-492-1687
Mailing Address - Fax:866-216-6527
Practice Address - Street 1:934 NE 8TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1641
Practice Address - Country:US
Practice Address - Phone:541-492-1687
Practice Address - Fax:866-216-6527
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRISDENTAL GROUP PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD85941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty