Provider Demographics
NPI:1447553409
Name:PREVENTIVE DENTAL LLC
Entity type:Organization
Organization Name:PREVENTIVE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL HYGIENIST
Authorized Official - Prefix:
Authorized Official - First Name:ZINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURT
Authorized Official - Suffix:
Authorized Official - Credentials:RDH, LAP
Authorized Official - Phone:541-231-3212
Mailing Address - Street 1:1610 NW MENLO DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-2055
Mailing Address - Country:US
Mailing Address - Phone:541-231-3212
Mailing Address - Fax:
Practice Address - Street 1:1610 NW MENLO DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-2055
Practice Address - Country:US
Practice Address - Phone:541-231-3212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH3040124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty