Healthcare Provider Details

I. General information

NPI: 1992085252
Provider Name (Legal Business Name): INLAND SHORES FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2011
Last Update Date: 08/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5830 SHOREVIEW LN N
KEIZER OR
97303-3866
US

IV. Provider business mailing address

5830 SHOREVIEW LN N
KEIZER OR
97303-3866
US

V. Phone/Fax

Practice location:
  • Phone: 503-390-4117
  • Fax: 503-390-8342
Mailing address:
  • Phone: 503-390-4117
  • Fax: 503-390-8342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD8434
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MEGAN PETERSON
Title or Position: OWNER/DENTIST
Credential: D.M.D.
Phone: 503-390-4117