MEDICARE: EQUITY DENTAL CLINICS KLAMATH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1568283398
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EQUITY DENTAL CLINICS KLAMATH, LLC

Provider Business Mailing Address
First Line	:	PO BOX 1748
Second Line	:
City	:	REDMOND
State	:	OR
Zip	:	97756-0518
Country	:	US
Telephone Number	:	541-680-9028
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 BRYANT WILLIAMS DR
Second Line	:
City	:	KLAMATH FALLS
State	:	OR
Zip	:	97601-1120
Country	:	US
Telephone Number	:	541-680-9028
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MIKE SHIRTCLIFF
Credential	:	DMD
Telephone Number	:	541-680-9028

Provider Enumeration Date	:	10/23/2024
Last Update Date	:	06/19/2026

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