Healthcare Provider Details

I. General information

NPI: 1366738858
Provider Name (Legal Business Name): EUGENE KIDS' DENTIST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2011
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4122 QUEST DR.
EUGENE OR
97402
US

IV. Provider business mailing address

4122 QUEST DR.
EUGENE OR
97402
US

V. Phone/Fax

Practice location:
  • Phone: 541-844-1667
  • Fax:
Mailing address:
  • Phone: 541-844-1667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: TIMOTHY RICHARDSON
Title or Position: DR. / OWNER
Credential: DDS
Phone: 541-844-1667