Provider Demographics
NPI:1124858477
Name:CENTENNIAL FAMILY DENTAL PC
Entity type:Organization
Organization Name:CENTENNIAL FAMILY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GREGERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:CDA, EFDA
Authorized Official - Phone:541-741-0602
Mailing Address - Street 1:1290 W CENTENNIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-3566
Mailing Address - Country:US
Mailing Address - Phone:541-741-0602
Mailing Address - Fax:541-741-0615
Practice Address - Street 1:1290 W CENTENNIAL BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-3566
Practice Address - Country:US
Practice Address - Phone:541-741-0602
Practice Address - Fax:541-741-0615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty