Provider Demographics
NPI:1720718653
Name:BROOKSIDE DENTAL-CANBY, LLC
Entity type:Organization
Organization Name:BROOKSIDE DENTAL-CANBY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-914-8221
Mailing Address - Street 1:22400 SALAMO RD STE 102
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-8269
Mailing Address - Country:US
Mailing Address - Phone:503-723-8722
Mailing Address - Fax:
Practice Address - Street 1:1514 SE 3RD CT
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-4560
Practice Address - Country:US
Practice Address - Phone:503-266-2033
Practice Address - Fax:503-468-5925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1376532291OtherNPI TYPE 1