=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003295015
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELM STREET DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2015
-----------------------------------------------------
Last Update Date | 05/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1036 ELM ST SW
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97321-2039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-928-2993
-----------------------------------------------------
Fax | 541-926-0339
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1036 ELM ST SW
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97321-2039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-928-2993
-----------------------------------------------------
Fax | 541-926-0339
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. LANE S HARRIS
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 541-928-2993
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D9733
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D7193
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------