Healthcare Provider Details

I. General information

NPI: 1730417106
Provider Name (Legal Business Name): PAHLS DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2009
Last Update Date: 11/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

346 N. CENTRAL BLVD
COQUILLE OR
97423
US

IV. Provider business mailing address

346 N. CENTRAL BLVD
COQUILLE OR
97423
US

V. Phone/Fax

Practice location:
  • Phone: 541-396-2242
  • Fax: 541-396-3860
Mailing address:
  • Phone: 541-396-2242
  • Fax: 541-396-3860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD8932
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD8651
License Number StateOR

VIII. Authorized Official

Name: DR. CHRISTIAN BRENT PAHLS
Title or Position: GENERAL DENTIST
Credential: D.D.S.
Phone: 541-396-2242