Provider Demographics
NPI:1023568631
Name:SALEM DENTAL LLC
Entity type:Organization
Organization Name:SALEM DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYANT
Authorized Official - Middle Name:
Authorized Official - Last Name:ZOLLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-648-6671
Mailing Address - Street 1:324 SE 9TH AVE STE B
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4247
Mailing Address - Country:US
Mailing Address - Phone:503-648-6671
Mailing Address - Fax:503-693-1143
Practice Address - Street 1:2510 12TH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2167
Practice Address - Country:US
Practice Address - Phone:503-378-1212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST DENTAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD100361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty