Healthcare Provider Details

I. General information

NPI: 1508855230
Provider Name (Legal Business Name): CAROLYN M. CANTRELL DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 WILLAMETTE ST SUITE B
EUGENE OR
97405-2890
US

IV. Provider business mailing address

2233 WILLAMETTE ST SUITE B
EUGENE OR
97405-2890
US

V. Phone/Fax

Practice location:
  • Phone: 541-687-2156
  • Fax: 541-684-9268
Mailing address:
  • Phone: 541-687-2156
  • Fax: 541-684-9268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD6877
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier119524
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: