Provider Demographics
NPI:1942738588
Name:MOSAIC MEDICAL DENTAL
Entity type:Organization
Organization Name:MOSAIC MEDICAL DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:LANGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-383-3005
Mailing Address - Street 1:600 SW COLUMBIA ST STE 6210
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1099
Mailing Address - Country:US
Mailing Address - Phone:541-383-3005
Mailing Address - Fax:
Practice Address - Street 1:1250 SW VETERANS WAY
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-2585
Practice Address - Country:US
Practice Address - Phone:541-923-4462
Practice Address - Fax:541-383-1883
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOSAIC MEDICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-26
Last Update Date:2017-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR182960Medicaid