Provider Demographics
NPI:1821104407
Name:CANTERBURY DENTAL, LLC
Entity Type:Organization
Organization Name:CANTERBURY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARVEL
Authorized Official - Middle Name:LERALPH
Authorized Official - Last Name:STANDER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-620-9333
Mailing Address - Street 1:14465 SW PACIFIC HWY
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-3662
Mailing Address - Country:US
Mailing Address - Phone:503-620-9333
Mailing Address - Fax:503-620-5355
Practice Address - Street 1:14465 SW PACIFIC HWY
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-3662
Practice Address - Country:US
Practice Address - Phone:503-620-9333
Practice Address - Fax:503-620-5355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD68001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty