1811164155 NPI number — CRISCIONE FAMILY DENTISTRY, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811164155 NPI number — CRISCIONE FAMILY DENTISTRY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRISCIONE FAMILY DENTISTRY, PC
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:
1811164155
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97302-8001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-636-7601
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3975 MERCANTILE DR
Provider Second Line Business Practice Location Address:
#150
Provider Business Practice Location Address City Name:
LAKE OSWEGO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97035-3595
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-636-7601
Provider Business Practice Location Address Fax Number:
503-636-3749
Provider Enumeration Date:
05/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KREKOS
Authorized Official First Name:
DEBBIE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
503-636-7601

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  6583 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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