Provider Demographics
NPI:1053323618
Name:SLACK, MOLLY (DDS)
Entity type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:
Last Name:SLACK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-1254
Mailing Address - Country:US
Mailing Address - Phone:541-258-7884
Mailing Address - Fax:541-258-7834
Practice Address - Street 1:1200 W OAK ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-1254
Practice Address - Country:US
Practice Address - Phone:541-258-7884
Practice Address - Fax:541-258-7834
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7600122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist