Healthcare Provider Details

I. General information

NPI: 1609704345
Provider Name (Legal Business Name): PAVENTY & BROWN ORTHODONTICS II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 E ELLENDALE AVE STE 2
DALLAS OR
97338-3052
US

IV. Provider business mailing address

410 E ELLENDALE AVE STE 2
DALLAS OR
97338-3052
US

V. Phone/Fax

Practice location:
  • Phone: 971-468-0220
  • Fax: 971-468-0220
Mailing address:
  • Phone: 971-468-0220
  • Fax: 971-468-0220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CASSANDRA WIETH
Title or Position: DIRECTOR OF PAYER RELATIONS
Credential:
Phone: 623-267-8121