Healthcare Provider Details

I. General information

NPI: 1497823546
Provider Name (Legal Business Name): MILL CREEK DENTAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 N 1ST AVE
STAYTON OR
97383-1703
US

IV. Provider business mailing address

521 N 1ST AVE
STAYTON OR
97383-1703
US

V. Phone/Fax

Practice location:
  • Phone: 503-769-9699
  • Fax: 503-769-8599
Mailing address:
  • Phone: 503-769-9699
  • Fax: 503-769-8599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD6854
License Number StateOR

VIII. Authorized Official

Name: DR. TIMOTHY WILLLIAM BURNS
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 503-769-9699