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General NPI Number Information
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NPI Number | 1831603018
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Entity Type | Organization
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Legal Business Name | SPRINGFIELD KIDS DENTIST LLC
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Dates
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Enumeration Date | 11/26/2017
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Last Update Date | 11/26/2017
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Provider Practice Location Address
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Address Line | 5895 MAIN ST
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City | SPRINGFIELD
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State | OR
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Zip | 97478-6961
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Country | US
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Telephone | 541-654-4996
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Fax | 541-505-8463
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Provider Business Mailing Address
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Address Line | 5895 MAIN ST
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City | SPRINGFIELD
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State | OR
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Zip | 97478-6961
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Country | US
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Telephone | 541-654-4996
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Fax | 541-505-8463
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Authorized Official
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Title or Position | OPERATIONS OFFICER
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Name | FEMINA JANE BEDOLLA
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Credential |
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Telephone | 541-844-3113
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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 | D8929
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License Number State | OR
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