Healthcare Provider Details

I. General information

NPI: 1114017639
Provider Name (Legal Business Name): MECKLER DENTAL PROVIDERS (OREGON), INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 02/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 NAVARRE AVE STE 12
OREGON OH
43616-3459
US

IV. Provider business mailing address

7160 NORTH DALLAS PARKWAY ST 400
PLANO TX
55486-7145
US

V. Phone/Fax

Practice location:
  • Phone: 419-690-0320
  • Fax: 216-584-1078
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: RACHEL NITTINGER
Title or Position: MANAGER, CREDENTIALING
Credential:
Phone: 972-755-0816