Provider Demographics
NPI:1467253161
Name:CTR DENTAL NORTHWEST
Entity type:Organization
Organization Name:CTR DENTAL NORTHWEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MCKAY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-471-8308
Mailing Address - Street 1:1683 W HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2812
Mailing Address - Country:US
Mailing Address - Phone:678-471-8308
Mailing Address - Fax:
Practice Address - Street 1:1683 W HARVARD AVE
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2812
Practice Address - Country:US
Practice Address - Phone:678-471-8308
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty