1205628104 NPI number — EVERGREEN SMILES

Table of content: (NPI 1205628104)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205628104 NPI number — EVERGREEN SMILES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN SMILES
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:
1205628104
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7015 RIVA RIDGE DR SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TURNER
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97392-9455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
289 E ELLENDALE AVE STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97338-1541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-876-5404
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2025

Additional Information

Authorized Official

Authorized Official Last Name:
WEEKS
Authorized Official First Name:
TANNER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
770-876-5404

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)

  • Identifier: 1881433670 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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