Healthcare Provider Details

I. General information

NPI: 1700522489
Provider Name (Legal Business Name): WATERFALL CLINIC INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2022
Last Update Date: 05/06/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1885 WAITE STREET
NORTH BEND OR
97459
US

IV. Provider business mailing address

1890 WAITE STREET SUITE 1
NORTH BEND OR
97459
US

V. Phone/Fax

Practice location:
  • Phone: 541-756-6232
  • Fax:
Mailing address:
  • Phone: 541-756-6232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ANDREA TRENNER
Title or Position: CEO
Credential:
Phone: 541-756-6232