Healthcare Provider Details

I. General information

NPI: 1790192342
Provider Name (Legal Business Name): LEBARON DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2014
Last Update Date: 07/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3975 RIVER RD N STE 5
KEIZER OR
97303-4811
US

IV. Provider business mailing address

3975 RIVER RD N STE 5
KEIZER OR
97303-4811
US

V. Phone/Fax

Practice location:
  • Phone: 503-393-9106
  • Fax: 503-393-3053
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD9266
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. TRENTON LEBARON
Title or Position: MEMBER
Credential: D.M.D.
Phone: 503-393-9106