Basic Information
| Provider Information | |||||||||
| NPI: | 1245275866 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POVEY | ||||||||
| FirstName: | IRA | ||||||||
| MiddleName: | |||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3617 S PACIFIC HWY | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975018957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415356239 | ||||||||
| FaxNumber: | 5415354377 | ||||||||
| Practice Location | |||||||||
| Address1: | 249 NW 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | CANBY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970133601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712067134 | ||||||||
| FaxNumber: | 5415354377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D8424 | OR | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 022868 | 05 | OR | MEDICAID | 94-3096772 | 01 | TAX ID | OTHER |