Provider Demographics
NPI:1699258087
Name:LA LANDE, PHILIP JORDAN (DMD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:JORDAN
Last Name:LA LANDE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 LANCASTER DR NE STE 104
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1040
Mailing Address - Country:US
Mailing Address - Phone:503-587-9949
Mailing Address - Fax:
Practice Address - Street 1:1880 LANCASTER DR NE STE 104
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305
Practice Address - Country:US
Practice Address - Phone:503-587-9949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD109041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice