Healthcare Provider Details

I. General information

NPI: 1265698351
Provider Name (Legal Business Name): CASCADE ENDODONTIC GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2008
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1590 NE WILLIAMSON BLVD
BEND OR
97701-6071
US

IV. Provider business mailing address

1590 NE WILLIAMSON BLVD
BEND OR
97701-6071
US

V. Phone/Fax

Practice location:
  • Phone: 541-388-1500
  • Fax: 541-388-6995
Mailing address:
  • Phone: 541-388-1500
  • Fax: 541-388-6995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD8490
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD8211
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ELIZABETH EDMUNDS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 541-388-1500