Provider Demographics
NPI:1366756389
Name:MOUNTAIN VIEW ORAL SURGERY AND DENTAL IMPLANTS
Entity type:Organization
Organization Name:MOUNTAIN VIEW ORAL SURGERY AND DENTAL IMPLANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-472-1468
Mailing Address - Street 1:1046 NE 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-4418
Mailing Address - Country:US
Mailing Address - Phone:503-472-1468
Mailing Address - Fax:503-434-9214
Practice Address - Street 1:1046 NE 3RD ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-4418
Practice Address - Country:US
Practice Address - Phone:503-472-1468
Practice Address - Fax:503-434-9214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-02
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD92721223S0112X
ORD59641223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty