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General NPI Number Information
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NPI Number | 1790225399
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Entity Type | Organization
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Legal Business Name | CHILDRENS DENTISTRY
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Dates
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Enumeration Date | 03/01/2017
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Last Update Date | 03/01/2017
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Provider Practice Location Address
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Address Line | 515 W IDAHO AVE
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City | ONTARIO
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State | OR
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Zip | 97914-2348
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Country | US
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Telephone | 541-709-5500
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Fax | 208-467-5199
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Provider Business Mailing Address
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Address Line | 515 W IDAHO AVE
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City | ONTARIO
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State | OR
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Zip | 97914-2348
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Country | US
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Telephone | 541-709-5500
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Fax | 208-467-5199
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Authorized Official
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Title or Position | OWNER
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Name | DR. JEFFREY C BRYSON
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Credential | DDS
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Telephone | 208-467-5100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | D10349
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License Number State | OR
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