Provider Demographics
NPI:1871205393
Name:DEEPLY ROOTED DENTISTRY, LLC
Entity type:Organization
Organization Name:DEEPLY ROOTED DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:H
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-678-5060
Mailing Address - Street 1:461 NE GREENWOOD AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701
Mailing Address - Country:US
Mailing Address - Phone:541-678-5060
Mailing Address - Fax:541-306-4004
Practice Address - Street 1:461 NE GREENWOOD AVE
Practice Address - Street 2:SUITE C
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701
Practice Address - Country:US
Practice Address - Phone:541-678-5060
Practice Address - Fax:541-306-4004
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEEPLY ROOTED DENTISTRY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty