Provider Demographics
NPI:1538434014
Name:VILLAGE DENTAL
Entity type:Organization
Organization Name:VILLAGE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:YAN
Authorized Official - Middle Name:Z
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:503-582-8255
Mailing Address - Street 1:29174 SW TOWN CENTER LOOP W
Mailing Address - Street 2:201
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9306
Mailing Address - Country:US
Mailing Address - Phone:503-582-8255
Mailing Address - Fax:503-582-9355
Practice Address - Street 1:29174 SW TOWN CENTER LOOP W
Practice Address - Street 2:201
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9306
Practice Address - Country:US
Practice Address - Phone:503-582-8255
Practice Address - Fax:503-582-9355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD74291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty