NPIMap

Organization Active NPI

Waterfall Clinic Incorporated

Doing business as Waterfall Dental Services

  • General Practice Dentistry
  • North Bend, OR
National Provider Identifier
1700522489
Registry record updated May 6, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
Legal business name
WATERFALL CLINIC INCORPORATED
Doing business as
Waterfall Dental Services
Practice address
1885 Waite Street
North Bend, OR 97459
Phone
(541) 756-6232
NPI assigned
May 6, 2022
Last updated
May 6, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 6, 2022

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

Authorized official

Name
Andrea Trenner
Title
Ceo
Phone
(541) 756-6232

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice Dentistry 1223G0001X Primary

Addresses

Primary practice location

1885 Waite Street
North Bend, OR 97459

Mailing address

1890 Waite Street Suite 1
North Bend, OR 97459
Phone (541) 756-6232

Other names 1

  • Waterfall Dental Services Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230525001993 OR Part A Provider - Federally Qualified Health Center (FQHC) 5698740355 Practice locations: North Bend, OR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1700522489. Details of each certification follow.

Federally qualified health center certification: CCN 381014

Legal name
WATERFALL CLINIC INCORPORATED
Doing business as
WATERFALL DENTAL SERVICES
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 16, 2023
Last certification
Jun 16, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jan 11, 2000 in OR
Enrollment address
1885 Waite St
North Bend, OR 97459-1210

Other NPIs with the same Medicare PAC ID 4

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

National Provider Directory

National Provider Directory
Tax ID family
Waterfall Community Health Center8 organizations share this tax ID, including this one

Other organizations with this tax ID 7

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

Locations

1885 Waite St
North Bend, OR 97459
Phone (541) 756-1117

Ownership & related parties

All disclosed owners & managing parties 8

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Ashley Fass Individual Corporate Director May 1, 2022
Elizabeth Brigham Individual Corporate DirectorBoard Member Aug 1, 2020
Sandra Qualman Individual Corporate DirectorBoard Member Oct 1, 2007
Lance E Nelson Individual Contracted Managing EmployeeCeo Mar 1, 2023
Corporate OfficerCeo Mar 1, 2023
Norman Herning Individual Corporate DirectorBoard Member Oct 1, 2016
Marcelene Knight Individual Corporate DirectorBoard Member Jan 1, 1998
McClain Altman Individual Corporate DirectorBoard Member Aug 1, 2020
Teresea C Bratcher Individual Contracted Managing EmployeeFinance Manager Mar 1, 2009
Corporate DirectorFinance Manager Jan 1, 2022

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Waterfall School Based Health CenterCoos Bay, OR, CCN 381950 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Mar 16, 2014

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

NPI Registry JSON

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

{
    "created_epoch": "1651795200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1651795200000",
    "number": "1700522489",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1890 WAITE STREET SUITE 1",
            "city": "NORTH BEND",
            "state": "OR",
            "postal_code": "97459",
            "telephone_number": "541-756-6232"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1885 WAITE STREET",
            "city": "NORTH BEND",
            "state": "OR",
            "postal_code": "97459",
            "telephone_number": "541-756-6232"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WATERFALL CLINIC INCORPORATED",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-05-06",
        "last_updated": "2022-05-06",
        "certification_date": "2022-05-06",
        "status": "A",
        "authorized_official_last_name": "TRENNER",
        "authorized_official_first_name": "ANDREA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "541-756-6232"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Waterfall Dental Services",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in North Bend, OR

Sources for this page

Verify at the official NPI Registry.