Provider Demographics
NPI:1659192953
Name:INTREPID INNOVATIONS LLC
Entity type:Organization
Organization Name:INTREPID INNOVATIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL HYGIENIST
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HANKS
Authorized Official - Suffix:
Authorized Official - Credentials:EPDH
Authorized Official - Phone:919-592-9591
Mailing Address - Street 1:876 S 69TH PL
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-7315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1045 GATEWAY LOOP STE F
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-1128
Practice Address - Country:US
Practice Address - Phone:541-632-2123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental