Healthcare Provider Details

I. General information

NPI: 1316391857
Provider Name (Legal Business Name): TOM LASTER DDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2444 NW PROFESSIONAL DR
CORVALLIS OR
97330
US

IV. Provider business mailing address

2444 NW PROFESSIONAL DR
CORVALLIS OR
97330-3991
US

V. Phone/Fax

Practice location:
  • Phone: 541-758-1505
  • Fax:
Mailing address:
  • Phone: 541-758-1505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1223G0001X
License Number StateOR

VIII. Authorized Official

Name: ANGELINA RUIZ
Title or Position: FRONT OFFICE
Credential:
Phone: 541-758-1505