Provider Demographics
NPI:1023274198
Name:MOLALLA FAMILY DENTAL, PC
Entity type:Organization
Organization Name:MOLALLA FAMILY DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:MCNEIL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-829-7677
Mailing Address - Street 1:128 ROSS ST
Mailing Address - Street 2:PO BOX 390
Mailing Address - City:MOLALLA
Mailing Address - State:OR
Mailing Address - Zip Code:97038-9390
Mailing Address - Country:US
Mailing Address - Phone:503-829-7677
Mailing Address - Fax:
Practice Address - Street 1:128 ROSS ST
Practice Address - Street 2:
Practice Address - City:MOLALLA
Practice Address - State:OR
Practice Address - Zip Code:97038-9390
Practice Address - Country:US
Practice Address - Phone:503-829-7677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9142261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental