Healthcare Provider Details

I. General information

NPI: 1447553409
Provider Name (Legal Business Name): PREVENTIVE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2010
Last Update Date: 12/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 NW MENLO DR
CORVALLIS OR
97330-2055
US

IV. Provider business mailing address

1610 NW MENLO DR
CORVALLIS OR
97330-2055
US

V. Phone/Fax

Practice location:
  • Phone: 541-231-3212
  • Fax:
Mailing address:
  • Phone: 541-231-3212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH3040
License Number StateOR

VIII. Authorized Official

Name: ZINA BURT
Title or Position: DENTAL HYGIENIST
Credential: RDH, LAP
Phone: 541-231-3212