NPIMap

Organization Active NPI

Mirror Pond Dental, LLC

  • Dentist
  • Vancouver, WA
National Provider Identifier
1548719461
Registry record updated Oct 4, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
License
DE60682826 Issued in WA
Legal business name
MIRROR POND DENTAL, LLC
Practice address
1412 NE 134TH St. Suite 120
Vancouver, WA 98685
Phone
(360) 573-4848
NPI assigned
Oct 4, 2016
Last updated
Oct 4, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 4, 2016

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

Authorized official

Name
Marc Andrew Nordstrom, DMD
Title
Member
Phone
(541) 610-7837

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
DentistGroup: 193400000X SINGLE SPECIALTY GROUP 122300000X DE60682826 WA Primary

Addresses

Primary practice location

1412 NE 134TH St. Suite 120
Vancouver, WA 98685

Mailing address

1475 SW Chandler Ave Ste 201
Bend, OR 97702-3240
Phone (541) 610-7837

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.

Locations

1412 NE 134th St
Ste 120
Vancouver, WA 98685
Phone (360) 573-4848

NPI Registry JSON

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

{
    "created_epoch": "1475539200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1475539200000",
    "number": "1548719461",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1475 SW CHANDLER AVE STE 201",
            "city": "BEND",
            "state": "OR",
            "postal_code": "977023240",
            "telephone_number": "541-610-7837"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1412 NE 134TH ST. SUITE 120",
            "city": "VANCOUVER",
            "state": "WA",
            "postal_code": "98685",
            "telephone_number": "360-573-4848"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MIRROR POND DENTAL, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-10-04",
        "last_updated": "2016-10-04",
        "status": "A",
        "authorized_official_last_name": "NORDSTROM",
        "authorized_official_first_name": "MARC",
        "authorized_official_middle_name": "ANDREW",
        "authorized_official_title_or_position": "MEMBER",
        "authorized_official_telephone_number": "541-610-7837",
        "authorized_official_credential": "DMD"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist",
            "state": "WA",
            "license": "DE60682826",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Vancouver, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 4, 2016; 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.