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General NPI Number Information
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NPI Number | 1568283398
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Entity Type | Organization
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Legal Business Name | EQUITY DENTAL CLINICS BURNS, LLC
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Dates
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Enumeration Date | 10/23/2024
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Last Update Date | 10/23/2024
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Provider Practice Location Address
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Address Line | 711 PONDEROSA VLG
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City | BURNS
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State | OR
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Zip | 97720-2315
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Country | US
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Telephone | 541-680-9028
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1748
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City | REDMOND
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State | OR
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Zip | 97756-0518
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Country | US
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Telephone | 541-680-9028
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MIKE SHIRTCLIFF
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Credential | DMD
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Telephone | 541-680-9028
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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