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General NPI Number Information
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NPI Number | 1255889333
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Entity Type | Organization
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Legal Business Name | CAPITOL DENTAL GROUP
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Dates
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Enumeration Date | 09/16/2016
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Last Update Date | 09/16/2016
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Provider Practice Location Address
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Address Line | 3000 MARKET ST NE SUITE 228
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City | SALEM
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State | OR
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Zip | 97301-1882
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Country | US
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Telephone | 503-587-7162
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Fax | 503-581-0043
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Provider Business Mailing Address
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Address Line | 3000 MARKET ST NE SUITE 228
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City | SALEM
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State | OR
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Zip | 97301-1882
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Country | US
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Telephone | 503-587-7162
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Fax | 503-581-0043
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Authorized Official
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Title or Position | DENTAL PROGRAM DIRECTOR
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Name | STACI COMER
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Credential |
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Telephone | 971-205-7475
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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 | H7259
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License Number State | OR
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