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General NPI Number Information
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NPI Number | 1831741958
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Entity Type | Organization
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Legal Business Name | ADVANTAGE DENTAL GROUP, PC
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Dates
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Enumeration Date | 07/09/2019
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Last Update Date | 10/25/2021
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Provider Practice Location Address
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Address Line | 300 TATONE
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City | BOARDMAN
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State | OR
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Zip | 97818
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Country | US
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Telephone | 541-945-4008
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Fax | 541-516-4041
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Provider Business Mailing Address
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Address Line | PO BOX 11470
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City | EUGENE
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State | OR
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Zip | 97440-3670
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Country | US
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Telephone | 541-945-4008
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Fax | 541-516-4041
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Authorized Official
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Title or Position | MANAGER, LICENSING AND CREDENTIALIN
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Name | SHARON EDMONDSON
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Credential |
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Telephone | 629-999-5014
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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