NPIMap

Organization Active NPI

Mirror Pond Dental, LLC

  • General Practice Dentistry
  • Bend, OR
National Provider Identifier
1225401052
Registry record updated Nov 2, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
D7335 Issued in OR
Legal business name
MIRROR POND DENTAL, LLC
Practice address
102 NW Newport Ave
Bend, OR 97703-1838
Phone
(541) 382-2256
Fax
(541) 389-5229
NPI assigned
Nov 2, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 2, 2015

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

Authorized official

Name
Marc Nordstrom, DMD
Title
Owner
Phone
(541) 382-2256

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223G0001X D7335 OR Primary

Addresses

Primary practice location

102 NW Newport Ave
Bend, OR 97703-1838

Mailing address

102 NW Newport Ave
Bend, OR 97703-1838
Phone (541) 382-2256

National Provider Directory

National Provider Directory
Tax ID family
Mirror Pond Dental LLC2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

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

{
    "created_epoch": "1446422400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1446422400000",
    "number": "1225401052",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "102 NW NEWPORT AVE",
            "city": "BEND",
            "state": "OR",
            "postal_code": "977031838",
            "telephone_number": "541-382-2256",
            "fax_number": "541-389-5229"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "102 NW NEWPORT AVE",
            "city": "BEND",
            "state": "OR",
            "postal_code": "977031838",
            "telephone_number": "541-382-2256",
            "fax_number": "541-389-5229"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MIRROR POND DENTAL, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-11-02",
        "last_updated": "2015-11-02",
        "status": "A",
        "authorized_official_last_name": "NORDSTROM",
        "authorized_official_first_name": "MARC",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "541-382-2256",
        "authorized_official_credential": "DMD"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": "OR",
            "license": "D7335",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Bend, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 2, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.