Provider Demographics
NPI:1225401052
Name:MIRROR POND DENTAL, LLC
Entity type:Organization
Organization Name:MIRROR POND DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:NORDSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-382-2256
Mailing Address - Street 1:102 NW NEWPORT AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-1838
Mailing Address - Country:US
Mailing Address - Phone:541-382-2256
Mailing Address - Fax:541-389-5229
Practice Address - Street 1:102 NW NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-1838
Practice Address - Country:US
Practice Address - Phone:541-382-2256
Practice Address - Fax:541-389-5229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD73351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty