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General NPI Number Information
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NPI Number | 1154747426
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Entity Type | Organization
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Legal Business Name | TILLAMOOK DENTURE CLINIC
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Dates
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Enumeration Date | 03/11/2014
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Last Update Date | 03/11/2014
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Provider Practice Location Address
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Address Line | 2505 MAIN AVE N
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City | TILLAMOOK
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State | OR
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Zip | 97141-9225
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Country | US
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Telephone | 503-354-2050
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Fax |
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Provider Business Mailing Address
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Address Line | 2505 MAIN AVE N
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City | TILLAMOOK
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State | OR
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Zip | 97141-9225
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Country | US
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Telephone | 503-354-2050
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Fax |
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Authorized Official
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Title or Position | OWNER-DENTURIST
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Name | MRS. MARGARETA HANIKYROVA-BORLAND
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Credential | DD.LD.
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Telephone | 503-354-2050
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DT-DO-10125318
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License Number State | OR
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