Healthcare Provider Details

I. General information

NPI: 1063545366
Provider Name (Legal Business Name): RONALD GRAHAM MCENTIRE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: R GRAHAM MCENTIRE DDS

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SOUTHGATE STE 3
PENDLETON OR
97801
US

IV. Provider business mailing address

1100 SOUTHGATE STE 3
PENDLETON OR
97801
US

V. Phone/Fax

Practice location:
  • Phone: 541-276-5272
  • Fax: 541-276-7212
Mailing address:
  • Phone: 541-276-5272
  • Fax: 541-276-7212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE00007097
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD10341
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: