Healthcare Provider Details

I. General information

NPI: 1285545608
Provider Name (Legal Business Name): GREAT SMILE DENTAL OF BEND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 NW HAWTHORNE AVE
BEND OR
97703-2918
US

IV. Provider business mailing address

124 NW HAWTHORNE AVE
BEND OR
97703-2918
US

V. Phone/Fax

Practice location:
  • Phone: 541-389-1301
  • Fax:
Mailing address:
  • Phone: 541-389-1301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER B AMUNDSON
Title or Position: DENTIST/OWNER
Credential: DMD
Phone: 303-521-2916