Provider Demographics
NPI:1770751224
Name:BASIN DENTAL CARE, P.C.
Entity type:Organization
Organization Name:BASIN DENTAL CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:LEROY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-884-4550
Mailing Address - Street 1:2530 SHASTA WAY
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-4356
Mailing Address - Country:US
Mailing Address - Phone:541-884-4550
Mailing Address - Fax:541-884-4676
Practice Address - Street 1:2530 SHASTA WAY
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-4356
Practice Address - Country:US
Practice Address - Phone:541-884-4550
Practice Address - Fax:541-884-4676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR44481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR10844-9Medicaid