Provider Demographics
NPI:1558190033
Name:EQUITY DENTAL CLINIC, PC
Entity type:Organization
Organization Name:EQUITY DENTAL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIRTCLIFF
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-680-9028
Mailing Address - Street 1:PO BOX 1748
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-0518
Mailing Address - Country:US
Mailing Address - Phone:541-216-4469
Mailing Address - Fax:541-216-4725
Practice Address - Street 1:648 CHETCO AVE
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-8010
Practice Address - Country:US
Practice Address - Phone:541-216-4469
Practice Address - Fax:541-216-4725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-31
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty