=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497190821
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH LANE CHILDREN'S DENTAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2013
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1275 S RIVER RD
-----------------------------------------------------
City | COTTAGE GROVE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97424-3906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-520-7137
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1275 S RIVER RD
-----------------------------------------------------
City | COTTAGE GROVE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97424-3906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-520-7137
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTAL CARE COORDINATOR
-----------------------------------------------------
Name | MRS. COURTNEY JANE LONG
-----------------------------------------------------
Credential | EFDA
-----------------------------------------------------
Telephone | 541-520-7137
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251V00000X
-----------------------------------------------------
Taxonomy Name | Voluntary or Charitable Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------