Healthcare Provider Details

I. General information

NPI: 1568283398
Provider Name (Legal Business Name): EQUITY DENTAL CLINICS KLAMATH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 BRYANT WILLIAMS DR
KLAMATH FALLS OR
97601-1120
US

IV. Provider business mailing address

PO BOX 1748
REDMOND OR
97756-0518
US

V. Phone/Fax

Practice location:
  • Phone: 541-680-9028
  • Fax:
Mailing address:
  • Phone: 541-680-9028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MIKE SHIRTCLIFF
Title or Position: PRESIDENT
Credential: DMD
Phone: 541-680-9028