Provider Demographics
NPI:1649573585
Name:ADVANTAGE DENTAL ASSOCIATES OF CROOK COUNTY, LLC
Entity type:Organization
Organization Name:ADVANTAGE DENTAL ASSOCIATES OF CROOK COUNTY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:DR
Authorized Official - First Name:R. MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIRTCLIFF
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-447-5838
Mailing Address - Street 1:257 NE 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-1910
Mailing Address - Country:US
Mailing Address - Phone:541-447-5838
Mailing Address - Fax:541-447-5883
Practice Address - Street 1:257 NE 2ND ST
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-1910
Practice Address - Country:US
Practice Address - Phone:541-447-5838
Practice Address - Fax:541-447-5883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty