Provider Demographics
NPI:1427297662
Name:DOC GROK PC
Entity type:Organization
Organization Name:DOC GROK PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDELNOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-806-0662
Mailing Address - Street 1:PO BOX 901
Mailing Address - Street 2:
Mailing Address - City:SISTERS
Mailing Address - State:OR
Mailing Address - Zip Code:97759-0901
Mailing Address - Country:US
Mailing Address - Phone:541-549-0973
Mailing Address - Fax:
Practice Address - Street 1:354 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:SISTERS
Practice Address - State:OR
Practice Address - Zip Code:97759
Practice Address - Country:US
Practice Address - Phone:541-549-0973
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1223G0001X, 124Q00000X, 126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty