Healthcare Provider Details

I. General information

NPI: 1891902896
Provider Name (Legal Business Name): HHHKC DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2266 MISSION ST SE
SALEM OR
97302-1267
US

IV. Provider business mailing address

2266 MISSION ST SE
SALEM OR
97302-1267
US

V. Phone/Fax

Practice location:
  • Phone: 503-375-2000
  • Fax:
Mailing address:
  • Phone: 503-375-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MRS. KIM MARIE HARROUN
Title or Position: PRACTICE ADMIN
Credential:
Phone: 503-375-2000