Provider Demographics
NPI:1922424738
Name:CORNELIUS TENDERCARE DENTAL PC
Entity Type:Organization
Organization Name:CORNELIUS TENDERCARE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MAROSTICA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-858-0741
Mailing Address - Street 1:1890 BASELINE ST
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:OR
Mailing Address - Zip Code:97113-8208
Mailing Address - Country:US
Mailing Address - Phone:503-357-0004
Mailing Address - Fax:503-359-8856
Practice Address - Street 1:1890 BASELINE ST
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:OR
Practice Address - Zip Code:97113-8208
Practice Address - Country:US
Practice Address - Phone:503-357-0004
Practice Address - Fax:503-359-8856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9419261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental