Healthcare Provider Details

I. General information

NPI: 1790082592
Provider Name (Legal Business Name): MONROE AVE DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2011
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

853 NW MONROE AVE
CORVALLIS OR
97330-6352
US

IV. Provider business mailing address

853 NW MONROE AVE
CORVALLIS OR
97330-6352
US

V. Phone/Fax

Practice location:
  • Phone: 541-754-1550
  • Fax: 541-754-0558
Mailing address:
  • Phone: 541-754-1550
  • Fax: 541-754-0558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6102
License Number StateOR

VIII. Authorized Official

Name: DR. JANET PENNINGTON PETERSON
Title or Position: DENTIST/OWNER
Credential:
Phone: 541-754-1550