Healthcare Provider Details

I. General information

NPI: 1427200138
Provider Name (Legal Business Name): EUGENE ENDODOTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2008
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 WILLAMETTE ST STE E
EUGENE OR
97405-2890
US

IV. Provider business mailing address

2233 WILLAMETTE ST. SUITE E
EUGENE OR
97405-2890
US

V. Phone/Fax

Practice location:
  • Phone: 541-484-9018
  • Fax: 541-345-8037
Mailing address:
  • Phone: 541-484-9018
  • Fax: 541-345-8037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number8541
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DAVID EARL WILSON
Title or Position: OWNER
Credential: DDS
Phone: 541-484-9018