Provider Demographics
NPI:1902244619
Name:JED R. NORMAN DDS LLC
Entity Type:Organization
Organization Name:JED R. NORMAN DDS LLC
Other - Org Name:GLIDE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JED
Authorized Official - Middle Name:R
Authorized Official - Last Name:NORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-672-6511
Mailing Address - Street 1:1813 W HARVARD AVE STE 221
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-8704
Mailing Address - Country:US
Mailing Address - Phone:541-672-6511
Mailing Address - Fax:541-673-1892
Practice Address - Street 1:1813 W HARVARD AVE STE 221
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-8704
Practice Address - Country:US
Practice Address - Phone:541-672-6511
Practice Address - Fax:541-673-1892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8859122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278647Medicaid