Healthcare Provider Details

I. General information

NPI: 1114613338
Provider Name (Legal Business Name): ROSEBURG FAMILY DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1729 W HARVARD AVE STE 1
ROSEBURG OR
97471-2795
US

IV. Provider business mailing address

1729 W HARVARD AVE STE 1
ROSEBURG OR
97471-2795
US

V. Phone/Fax

Practice location:
  • Phone: 541-673-0131
  • Fax: 541-673-0176
Mailing address:
  • Phone: 541-673-0131
  • Fax: 541-673-0176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ANDREA S BRAUN
Title or Position: PRESIDENT OWNER
Credential: DDS
Phone: 541-673-0131