Healthcare Provider Details

I. General information

NPI: 1679196190
Provider Name (Legal Business Name): HEALTHY SMILES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2020
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 CATRON ST N
MONMOUTH OR
97361-2303
US

IV. Provider business mailing address

PO BOX 1541
ROSEBURG OR
97470-0360
US

V. Phone/Fax

Practice location:
  • Phone: 503-420-7389
  • Fax:
Mailing address:
  • Phone: 541-492-1687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BECKI ROSE
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 541-418-4311