Provider Demographics
NPI:1245275866
Name:POVEY, IRA (DDS)
Entity type:Individual
Prefix:
First Name:IRA
Middle Name:
Last Name:POVEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3617 S PACIFIC HWY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-8957
Mailing Address - Country:US
Mailing Address - Phone:541-535-6239
Mailing Address - Fax:541-535-4377
Practice Address - Street 1:249 NW 3RD AVE
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-3601
Practice Address - Country:US
Practice Address - Phone:971-206-7134
Practice Address - Fax:541-535-4377
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8424122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022868Medicaid
94-3096772OtherTAX ID