Family Dental Clinic

Primary specialty

DentistTaxonomy code 122300000X

License

D10117 Issued in OR

Legal business name

FAMILY DENTAL CLINIC

Practice address

607 NE 3Rd St
Prineville, OR 97754-2021

Phone

(541) 447-3855

Fax

(541) 416-9580

NPI assigned

Aug 12, 2014

Organization subpart

No

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

Authorized official

Name

James G. Petersen

Title

Owner/Dentist

Phone

(541) 447-3855

Specialties & licenses 1

Addresses

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

{
    "created_epoch": "1407801600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1407801600000",
    "number": "1629487897",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "607 NE 3RD ST",
            "city": "PRINEVILLE",
            "state": "OR",
            "postal_code": "977542021",
            "telephone_number": "541-447-3855",
            "fax_number": "541-416-9580"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "607 NE 3RD ST",
            "city": "PRINEVILLE",
            "state": "OR",
            "postal_code": "977542021",
            "telephone_number": "541-447-3855",
            "fax_number": "541-416-9580"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAMILY DENTAL CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-08-12",
        "last_updated": "2014-08-12",
        "status": "A",
        "authorized_official_last_name": "PETERSEN",
        "authorized_official_first_name": "JAMES",
        "authorized_official_middle_name": "G.",
        "authorized_official_title_or_position": "OWNER/DENTIST",
        "authorized_official_telephone_number": "541-447-3855"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist",
            "state": "OR",
            "license": "D10117",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Catherine Ann Doherty, L.M.T.
• Syndey Dowell
• Joseph Patrick Dursse
• Destiny Maria-Karine Eggert
• Paul Fairbanks, DDS
• Alia H Fern
• Tara Lee Fetterly, QMHA
• Leah Flegel, RN
• Austin Harrison Fleming, DPT, PT
• Raquel Flores

• Dentist in Prineville, OR
• Providers in Prineville, OR by specialty
• Dentist in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 12, 2014; 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.