Provider Demographics
NPI:1831633122
Name:ACORN DENTISTRY FOR KIDS - LEBANON, LLC
Entity type:Organization
Organization Name:ACORN DENTISTRY FOR KIDS - LEBANON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-852-0809
Mailing Address - Street 1:1780 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-3139
Mailing Address - Country:US
Mailing Address - Phone:503-874-4560
Mailing Address - Fax:503-874-4562
Practice Address - Street 1:1780 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-3139
Practice Address - Country:US
Practice Address - Phone:503-874-4560
Practice Address - Fax:503-874-4562
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACORN DENTISTRY FOR KIDS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9577261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental