Healthcare Provider Details

I. General information

NPI: 1083359467
Provider Name (Legal Business Name): CODY MORGAN LD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2022
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

432 LANCASTER DR NE
SALEM OR
97301-4728
US

IV. Provider business mailing address

432 LANCASTER DR NE
SALEM OR
97301-4728
US

V. Phone/Fax

Practice location:
  • Phone: 971-365-3900
  • Fax:
Mailing address:
  • Phone: 971-365-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDT-DO-10226580
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: