Healthcare Provider Details

I. General information

NPI: 1093440208
Provider Name (Legal Business Name): SKYLINE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2022
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2137 NE 4TH ST
BEND OR
97701-3824
US

IV. Provider business mailing address

2137 NE 4TH ST
BEND OR
97701-3824
US

V. Phone/Fax

Practice location:
  • Phone: 541-389-4807
  • Fax: 541-389-4807
Mailing address:
  • Phone: 541-389-4807
  • Fax: 541-389-4807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CORIANNE LUMMIS
Title or Position: OFFICE MANAGER
Credential:
Phone: 541-389-4807