Basic Information
| Provider Information | |||||||||
| NPI: | 1780759985 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAGLE POINT DENTAL GROUP,P.C. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 236 | ||||||||
| Address2: | |||||||||
| City: | EAGLE POINT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975240236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418262525 | ||||||||
| FaxNumber: | 5418262876 | ||||||||
| Practice Location | |||||||||
| Address1: | 217 W MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | EAGLE POINT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418262525 | ||||||||
| FaxNumber: | 5418262876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | OGAWA | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5418262525 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D6945 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.