Provider Demographics
NPI:1932412194
Name:VANMIERLO, LINDA G (DDS)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:G
Last Name:VANMIERLO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7843
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97475-0032
Mailing Address - Country:US
Mailing Address - Phone:541-554-0770
Mailing Address - Fax:
Practice Address - Street 1:895 COUNTRY CLUB RD
Practice Address - Street 2:SUITE C-100
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-6003
Practice Address - Country:US
Practice Address - Phone:541-685-7289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-16
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD 52511223G0001X
WADE000070501223G0001X
CA261931223G0001X
UT139251-99221223G0001X
MT17821223G0001X
HIDT18781223G0001X
IDD 19031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice