Healthcare Provider Details

I. General information

NPI: 1285903047
Provider Name (Legal Business Name): MEDICAL CENTER DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2011
Last Update Date: 12/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SOUTHGATE SUITE 17
PENDLETON OR
97801-3974
US

IV. Provider business mailing address

1100 SOUTHGATE SUITE 17
PENDLETON OR
97801-3974
US

V. Phone/Fax

Practice location:
  • Phone: 541-276-1561
  • Fax: 541-276-5743
Mailing address:
  • Phone: 541-276-1561
  • Fax: 541-276-5743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD9425
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD9454
License Number StateOR

VIII. Authorized Official

Name: DR. JASON LAMAR WALKER
Title or Position: OWNER
Credential: DMD
Phone: 541-276-1561