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NPI Code Detail

MEDICARE: BIRCH AVENUE DENTAL, INC.

MEDICARE: BIRCH AVENUE DENTAL, INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1122300000XDentistD6947OR

General Provider Information

NPI Number : 1841363348
Entity Type Code : Organization
Provider Name (Legal Business Name) : BIRCH AVENUE DENTAL, INC.
Provider Business Mailing Address
First Line : 1325 BIRCH AVE
Second Line :
City : COTTAGE GROVE
State : OR
Zip : 97424-1416
Country : US
Telephone Number : 541-942-2471
Fax Number : 541-942-9318
Provider Business Practice Location Address
First Line : 1325 BIRCH AVE
Second Line :
City : COTTAGE GROVE
State : OR
Zip : 97424-1416
Country : US
Telephone Number : 541-942-2471
Fax Number : 541-942-9318
Authorized Official
Title or Position : PRESIDENT
Name : DR. PARK W MCCLUNG
Credential : D.D.S.
Telephone Number : 541-942-2471
Provider Enumeration Date : 11/15/2006
Last Update Date : 08/22/2020

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1144393646 — DR. PARK W MCCLUNG D.D.S.
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Directions to “BIRCH AVENUE DENTAL, INC. ” Practice Location

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