Provider Demographics
NPI:1700165362
Name:MID-VALLEY DENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MID-VALLEY DENTAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:R
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-929-5227
Mailing Address - Street 1:3385 CENTER ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4609
Mailing Address - Country:US
Mailing Address - Phone:503-585-2030
Mailing Address - Fax:541-929-7649
Practice Address - Street 1:3385 CENTER ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4609
Practice Address - Country:US
Practice Address - Phone:503-585-2030
Practice Address - Fax:541-929-7649
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID-VALLEY DENTAL ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD79151223G0001X
ORD91071223G0001X
ORD90841223G0001X
ORD94511223G0001X
ORD95861223G0001X
ORD96141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty