Healthcare Provider Details

I. General information

NPI: 1801902101
Provider Name (Legal Business Name): DENTISTRY FOR CHILDREN NW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 WILLAMETTE ST A
EUGENE OR
97405
US

IV. Provider business mailing address

2215 WILLAMETTE ST A
EUGENE OR
97405
US

V. Phone/Fax

Practice location:
  • Phone: 541-345-4076
  • Fax: 541-686-4834
Mailing address:
  • Phone: 541-345-4076
  • Fax: 541-686-4834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number5897
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier5897
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerBOARD OF DENTISTRY

VIII. Authorized Official

Name: MRS. LYNSEY B WICKWIRE
Title or Position: PRACTICE MANAGER
Credential:
Phone: 541-345-4076