Healthcare Provider Details

I. General information

NPI: 1649293036
Provider Name (Legal Business Name): FAMILY DENTISTRY OF GOLD BEACH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29814 ELLENSBURG AVE
GOLD BEACH OR
97444-1600
US

IV. Provider business mailing address

PO BOX 1600 29814 ELLENSBURG
GOLD BEACH OR
97444-1600
US

V. Phone/Fax

Practice location:
  • Phone: 541-247-8000
  • Fax: 541-247-8888
Mailing address:
  • Phone: 541-247-8000
  • Fax: 541-247-8888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD6942
License Number StateOR

VIII. Authorized Official

Name: DR. HERMAN LIEM
Title or Position: CEO
Credential: D. D. S.
Phone: 541-247-8000