Provider Demographics
NPI:1780759985
Name:EAGLE POINT DENTAL GROUP,P.C.
Entity type:Organization
Organization Name:EAGLE POINT DENTAL GROUP,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:OGAWA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-826-2525
Mailing Address - Street 1:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:EAGLE POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97524-0236
Mailing Address - Country:US
Mailing Address - Phone:541-826-2525
Mailing Address - Fax:541-826-2876
Practice Address - Street 1:217 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:EAGLE POINT
Practice Address - State:OR
Practice Address - Zip Code:97524
Practice Address - Country:US
Practice Address - Phone:541-826-2525
Practice Address - Fax:541-826-2876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD6945122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty