Provider Demographics
NPI:1881969244
Name:SALEM ENDODONTIC ASSOCIATES
Entity type:Organization
Organization Name:SALEM ENDODONTIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:CHRISTIANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:503-363-6500
Mailing Address - Street 1:4342 LIBERTY RD S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-6171
Mailing Address - Country:US
Mailing Address - Phone:503-363-6500
Mailing Address - Fax:503-363-6292
Practice Address - Street 1:4342 LIBERTY RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-6171
Practice Address - Country:US
Practice Address - Phone:503-363-6500
Practice Address - Fax:503-363-6292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-19
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD58561223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty