Provider Demographics
NPI:1851833131
Name:NORTHWEST DENTAL ASSOCIATES -MEDFORD LLC
Entity Type:Organization
Organization Name:NORTHWEST DENTAL ASSOCIATES -MEDFORD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-779-3993
Mailing Address - Street 1:3551 E BARNETT RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7037
Mailing Address - Country:US
Mailing Address - Phone:541-779-3993
Mailing Address - Fax:541-779-3382
Practice Address - Street 1:3551 E BARNETT RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7037
Practice Address - Country:US
Practice Address - Phone:541-779-3993
Practice Address - Fax:541-779-3382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-17
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD86731223G0001X
ORD87681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1770660912OtherDENTAL
OR1962623603OtherDENTAL