Provider Demographics
NPI:1457548943
Name:SOUTH SALEM ORTHODONTICS LLC
Entity type:Organization
Organization Name:SOUTH SALEM ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BART
Authorized Official - Middle Name:L
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD,MS
Authorized Official - Phone:503-588-2404
Mailing Address - Street 1:1790 LIBERTY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-5159
Mailing Address - Country:US
Mailing Address - Phone:503-588-2404
Mailing Address - Fax:
Practice Address - Street 1:1790 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-5159
Practice Address - Country:US
Practice Address - Phone:503-588-2404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD88691223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty