Healthcare Provider Details

I. General information

NPI: 1801034335
Provider Name (Legal Business Name): DAN JOSEPH DETTMANN L.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2009
Last Update Date: 01/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33894 SE EASTGATE CIR
CORVALLIS OR
97333-2248
US

IV. Provider business mailing address

261 BODEN ST
JUNCTION CITY OR
97448-1525
US

V. Phone/Fax

Practice location:
  • Phone: 541-754-4901
  • Fax:
Mailing address:
  • Phone: 541-913-5609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDT-DO-433361
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: