Provider Demographics
NPI:1841363348
Name:BIRCH AVENUE DENTAL, INC.
Entity type:Organization
Organization Name:BIRCH AVENUE DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:MCCLUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-942-2471
Mailing Address - Street 1:1325 BIRCH AVE
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-1416
Mailing Address - Country:US
Mailing Address - Phone:541-942-2471
Mailing Address - Fax:541-942-9318
Practice Address - Street 1:1325 BIRCH AVE
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-1416
Practice Address - Country:US
Practice Address - Phone:541-942-2471
Practice Address - Fax:541-942-9318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD6947122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty