Healthcare Provider Details

I. General information

NPI: 1396016770
Provider Name (Legal Business Name): BEN A SUTTER DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2012
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 WILLAGILLESPIE RD SUITE 150
EUGENE OR
97401-6798
US

IV. Provider business mailing address

1045 WILLAGILLESPIE RD SUITE 150
EUGENE OR
97401-6798
US

V. Phone/Fax

Practice location:
  • Phone: 541-683-7500
  • Fax:
Mailing address:
  • Phone: 541-683-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD8728
License Number StateOR

VIII. Authorized Official

Name: SHELLY RENEE SUTTER
Title or Position: OFFICE MANAGER
Credential:
Phone: 503-463-4663