Provider Demographics
NPI:1710194675
Name:HIGH DESERT DENTAL
Entity type:Organization
Organization Name:HIGH DESERT DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RHETT
Authorized Official - Middle Name:
Authorized Official - Last Name:TIPTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-889-6614
Mailing Address - Street 1:271 SW 13TH ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-4530
Mailing Address - Country:US
Mailing Address - Phone:541-889-6614
Mailing Address - Fax:541-889-2164
Practice Address - Street 1:271 SW 13TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-4530
Practice Address - Country:US
Practice Address - Phone:541-889-6614
Practice Address - Fax:541-889-2164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7106261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022803Medicaid
OR075254Medicaid
1720159080OtherBEN PETERSON NPI NUMBER
OR231468Medicaid
1578586194OtherNPI NUMBER TIPTON