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General NPI Number Information
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NPI Number | 1609043157
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Entity Type | Organization
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Legal Business Name | EASTERN OREGON DENTAL CLINIC LLC
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Dates
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Enumeration Date | 05/14/2008
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Last Update Date | 05/14/2008
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Provider Practice Location Address
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Address Line | 475 SW 12TH ST
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City | ONTARIO
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State | OR
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Zip | 97914-3201
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Country | US
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Telephone | 541-881-1794
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Fax | 541-889-2904
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Provider Business Mailing Address
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Address Line | 478 SW 12TH ST
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City | ONTARIO
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State | OR
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Zip | 97914-3202
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Country | US
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Telephone | 541-881-1794
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Fax | 541-889-2904
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Authorized Official
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Title or Position | MEMBER
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Name | DR. ERIC N DAHLE
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Credential | DMD
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Telephone | 541-881-1794
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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 | D9048
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D6574
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D7219
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License Number State | OR
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Taxonomy #4
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | D9048
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License Number State | OR
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Taxonomy #5
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | D6574
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License Number State | OR
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Taxonomy #6
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | D7219
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License Number State | OR
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Taxonomy #7
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D9048
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License Number State | OR
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Taxonomy #8
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D7219
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License Number State | OR
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Taxonomy #9
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | D6574
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License Number State | OR
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Taxonomy #10
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | D9048
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License Number State | OR
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Taxonomy #11
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | D7219
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License Number State | OR
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Taxonomy #12
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | D9048
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License Number State | OR
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Taxonomy #13
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | D6574
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License Number State | OR
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Taxonomy #14
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | D7219
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License Number State | OR
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Taxonomy #15
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D6574
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License Number State | OR
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