Healthcare Provider Details

I. General information

NPI: 1033539663
Provider Name (Legal Business Name): LANE COMMUNITY COLLEGE DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 04/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 WILLAMETTE ST
EUGENE OR
97405-3169
US

IV. Provider business mailing address

4000 E 30TH AVE DIVISION OF HEALTH PROFESSIONS, BUILDING 30
EUGENE OR
97405-0640
US

V. Phone/Fax

Practice location:
  • Phone: 541-463-5206
  • Fax: 541-463-4178
Mailing address:
  • Phone: 541-463-5618
  • Fax: 541-463-4167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberD5275
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. SHERYL BERMAN
Title or Position: DEAN OF HEALTH PROFESSIONS, LCC
Credential: PH.D
Phone: 541-463-5618