Provider Demographics
NPI: | 1801216643 |
---|---|
Name: | WILLAMETTE VALLEY ENDODONTICS, PC |
Entity Type: | Organization |
Organization Name: | WILLAMETTE VALLEY ENDODONTICS, PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | VICE-PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | TAI |
Authorized Official - Middle Name: | DOAN |
Authorized Official - Last Name: | TRUONG |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DMD |
Authorized Official - Phone: | 503-378-1334 |
Mailing Address - Street 1: | 805 HIGH ST NE |
Mailing Address - Street 2: | |
Mailing Address - City: | SALEM |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97301-2442 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 503-378-1334 |
Mailing Address - Fax: | 503-581-9464 |
Practice Address - Street 1: | 805 HIGH ST NE |
Practice Address - Street 2: | |
Practice Address - City: | SALEM |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97301-2442 |
Practice Address - Country: | US |
Practice Address - Phone: | 503-378-1334 |
Practice Address - Fax: | 503-581-9464 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2014-04-20 |
Last Update Date: | 2014-04-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OR | 1223E0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223E0200X | Dental Providers | Dentist | Endodontics | Group - Single Specialty |