Provider Demographics
NPI:1194083428
Name:MCMINNVILLE DENTAL GROUP
Entity type:Organization
Organization Name:MCMINNVILLE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCOULLIER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-472-2181
Mailing Address - Street 1:2550 NE MCDONALD LN
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-2223
Mailing Address - Country:US
Mailing Address - Phone:503-472-2181
Mailing Address - Fax:
Practice Address - Street 1:2550 NE MCDONALD LN
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-2223
Practice Address - Country:US
Practice Address - Phone:503-472-2181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD77971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty