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General NPI Number Information
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NPI Number | 1184169252
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Entity Type | Organization
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Legal Business Name | NPDG-2, LLC
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Dates
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Enumeration Date | 12/28/2016
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Last Update Date | 12/28/2016
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Provider Practice Location Address
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Address Line | 1310 NW HARRISON BLVD
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City | CORVALLIS
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State | OR
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Zip | 97330-5916
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Country | US
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Telephone | 541-753-8365
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Fax |
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Provider Business Mailing Address
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Address Line | 1310 NW HARRISON BLVD
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City | CORVALLIS
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State | OR
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Zip | 97330-5916
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Country | US
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Telephone | 541-753-8365
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARK P SWENSEN
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Credential | DDS
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Telephone | 541-753-8365
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D6570
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D10522
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D9063
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License Number State | OR
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