Provider Demographics
NPI:1609113703
Name:OREGON PIP DENTAL GROUP, PC
Entity type:Organization
Organization Name:OREGON PIP DENTAL GROUP, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELLISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:RENNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-667-4145
Mailing Address - Street 1:1935 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3390
Mailing Address - Country:US
Mailing Address - Phone:541-296-8901
Mailing Address - Fax:
Practice Address - Street 1:1935 E 19TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3390
Practice Address - Country:US
Practice Address - Phone:541-296-8901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-09
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR76661223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty