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Organization Active NPI

Silver Falls Dermatology, LLC

Doing business as Frontier Dermatology

  • Dermatology Physician
  • Salem, OR
National Provider Identifier
1134375421
Registry record updated Oct 17, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
SILVER FALLS DERMATOLOGY, LLC
Doing business as
Frontier Dermatology
Practice address
1793 13TH St SE
Salem, OR 97302-2541
Phone
(503) 362-8385
Fax
(503) 362-8435
NPI assigned
Aug 18, 2008
Last updated
Oct 17, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 17, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Malissa Kobbevik
Title
Credentialing Manager
Phone
(360) 375-2038

Specialties & licenses 8

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X
Nurse Practitioner 363L00000X
Dermatology Physician 207N00000X MD26178 OR
Dermatology Physician 207N00000X Primary
MOHS-Micrographic Surgery Physician 207ND0101X
Dermatopathology Physician 207ND0900X
Clinical & Laboratory Dermatological Immunology Physician 207NI0002X
Procedural Dermatology Physician 207NS0135X

Addresses

Primary practice location

1793 13TH St SE
Salem, OR 97302-2541

Mailing address

1793 13TH St SE
Salem, OR 97302-2541
Phone (503) 362-8385

Other identifiers 2

IdentifierTypeStateIssuer
2034282MedicaidWA
247588MedicaidOR

Other names 2

  • FRONTIER DERMATOLOGY Doing business as
  • Silver Falls Dermatology, PC Former legal business name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR, WA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20081009000466 OR Part B Supplier - Clinic/Group Practice 5890863492 Receives reassigned benefits from 34 practitioners
Practice locations: Astoria, OR; Woodburn, OR; Sherwood, OR; Seaside, OR; Salem, OR; Portland, OR; Pendleton, OR; Newport, OR…
O20140328000678 WA Part B Supplier - Clinic/Group Practice 5890863492 Receives reassigned benefits from 86 practitioners
Practice locations: Aberdeen, WA; Vancouver, WA; Sequim, WA; Seattle, WA; Poulsbo, WA; Port Angeles, WA; Olympia, WA; Mount Vernon, WA…

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory

Locations

1390 Waverly Dr SE
Ste 100
Albany, OR 97322

415 N State St
Ste 170
Lake Oswego, OR 97034

3132 State St
Ste 210
Medford, OR 97504
Phone (541) 414-0503

9755 SW Barnes Rd
Ste 450
Portland, OR 97225

1793 13th St SE
Salem, OR 97302
Phone 50336283851283

1006 N H St
Fl 3
Aberdeen, WA 98520
Phone (360) 533-6300

1020 Anderson Dr
Ste 204
Aberdeen, WA 98520
Phone (360) 986-3004

16410 Smokey Point Blvd
Ste 300
Arlington, WA 98223

4540 Cordata Pkwy
Ste 101
Bellingham, WA 98226
Phone (360) 255-5049

5 NE 4th St
Ste B
Coupeville, WA 98239
Phone (360) 336-3026

21600 Highway 99
Ste 110
Edmonds, WA 98026
Phone (206) 525-1168

21727 76th Ave W
Ste H
Edmonds, WA 98026
Phone (425) 672-1333

3131 Nassau St
#101
Everett, WA 98201
Phone (425) 339-8888

700 S 320th St
Ste A
Federal Way, WA 98003
Phone (253) 246-2435

8435 SE 68th St
Ste 118
Mercer Island, WA 98040
Phone (206) 232-7546

15906 Mill Creek Blvd
Ste 107
Mill Creek, WA 98012
Phone (206) 245-6844

1600 Continental Pl
Mount Vernon, WA 98273
Phone (360) 336-3026

3825 Martin Way E
Ste 104
Olympia, WA 98506
Phone (971) 915-8579

4407 Fairmount Ave
Port Angeles, WA 98363
Phone (360) 457-0760

19917 7th Ave NE
Ste 203
Poulsbo, WA 98370
Phone (360) 824-5474

350 S 38th Ct
Ste 115
Renton, WA 98055
Phone (206) 859-5777

11011 Meridian Ave N
Ste 102
Seattle, WA 98133
Phone (206) 859-5777

11011 Meridian Ave N
Ste 308
Seattle, WA 98133
Phone (206) 859-5777

5350 Tallman Ave NW
Ste 510
Seattle, WA 98107
Phone (206) 470-1850

Practitioners & affiliated clinicians

Practitioners 138

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 138

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1219017600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1729123200000",
    "number": "1134375421",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1793 13TH ST SE",
            "city": "SALEM",
            "state": "OR",
            "postal_code": "973022541",
            "telephone_number": "503-362-8385",
            "fax_number": "503-362-8435"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1793 13TH ST SE",
            "city": "SALEM",
            "state": "OR",
            "postal_code": "973022541",
            "telephone_number": "503-362-8385",
            "fax_number": "503-362-8435"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SILVER FALLS DERMATOLOGY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-08-18",
        "last_updated": "2024-10-17",
        "certification_date": "2024-10-17",
        "status": "A",
        "authorized_official_last_name": "KOBBEVIK",
        "authorized_official_first_name": "MALISSA",
        "authorized_official_title_or_position": "CREDENTIALING MANAGER",
        "authorized_official_telephone_number": "360-375-2038"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "OR",
            "license": "MD26178",
            "primary": false
        },
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207ND0101X",
            "taxonomy_group": "",
            "desc": "Dermatology, MOHS-Micrographic Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207ND0900X",
            "taxonomy_group": "",
            "desc": "Dermatology, Dermatopathology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207NI0002X",
            "taxonomy_group": "",
            "desc": "Dermatology, Clinical & Laboratory Dermatological Immunology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207NS0135X",
            "taxonomy_group": "",
            "desc": "Dermatology, Procedural Dermatology",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2034282",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "247588",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "FRONTIER DERMATOLOGY",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Silver Falls Dermatology, PC",
            "code": "4",
            "type": "Former Legal Business Name"
        },
        {
            "organization_name": "Silver Falls Dermatology, PC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Salem, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 17, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.