Basic Information
| Provider Information | |||||||||
| NPI: | 1801110994 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WOODBURN COSMETIC & FAMILY DENTISTRY P.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1018 N. BOONES FERRY RD. | ||||||||
| Address2: | |||||||||
| City: | WOODBURN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039811841 | ||||||||
| FaxNumber: | 5039817334 | ||||||||
| Practice Location | |||||||||
| Address1: | 1018 N. BOONES FERRY RD. | ||||||||
| Address2: | |||||||||
| City: | WOODBURN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039811841 | ||||||||
| FaxNumber: | 5039817334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2010 | ||||||||
| LastUpdateDate: | 03/18/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BLAKLEY | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5039811841 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D6259 | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.