Provider Demographics
NPI:1447812813
Name:ADVANTAGE DENTAL GROUP, PC
Entity type:Organization
Organization Name:ADVANTAGE DENTAL GROUP, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANGER, LICENSING & CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMONDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:629-999-5014
Mailing Address - Street 1:PO BOX 11470
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-3670
Mailing Address - Country:US
Mailing Address - Phone:888-468-0022
Mailing Address - Fax:
Practice Address - Street 1:1275 OREGON AVE SE
Practice Address - Street 2:
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-9102
Practice Address - Country:US
Practice Address - Phone:541-551-4022
Practice Address - Fax:541-516-4058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-05
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500694195Medicaid