Healthcare Provider Details

I. General information

NPI: 1265907364
Provider Name (Legal Business Name): PNW DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2018
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 COBURG RD STE 2
EUGENE OR
97401-4986
US

IV. Provider business mailing address

1814 COBURG RD STE 2
EUGENE OR
97401-4986
US

V. Phone/Fax

Practice location:
  • Phone: 541-342-3398
  • Fax:
Mailing address:
  • Phone: 541-342-3398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
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: DR. SUSAN N WATKINS
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 541-603-6696