1184053993 NPI number — FOOTHILLS FAMILY DENTAL LLC

Table of content: SAMANTHA SHUE LIEU PHARM.D. (NPI 1538572193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184053993 NPI number — FOOTHILLS FAMILY DENTAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOTHILLS FAMILY DENTAL LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184053993
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 770
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT ANGEL
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97362-0770
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-845-6891
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
710 FOOTHILLS DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWBERG
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97132-6125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-845-6891
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PIER
Authorized Official First Name:
SHAUNA
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
503-845-6891

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)