Provider Demographics
NPI:1831603018
Name:SPRINGFIELD KIDS DENTIST LLC
Entity type:Organization
Organization Name:SPRINGFIELD KIDS DENTIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:FEMINA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:BEDOLLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-844-3113
Mailing Address - Street 1:5895 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-6961
Mailing Address - Country:US
Mailing Address - Phone:541-654-4996
Mailing Address - Fax:541-505-8463
Practice Address - Street 1:5895 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97478-6961
Practice Address - Country:US
Practice Address - Phone:541-654-4996
Practice Address - Fax:541-505-8463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-26
Last Update Date:2017-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD89291223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR279295Medicaid
1528268281OtherPRIVATE INSURANCE