MEDICARE: CLOVER PEDIATRIC DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1003599689
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLOVER PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	2235 MISSION ST SE STE 250
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-1294
Country	:	US
Telephone Number	:	541-990-0363
Fax Number	:

Provider Business Practice Location Address
First Line	:	2225 MISSION ST SE STE 150
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-1296
Country	:	US
Telephone Number	:	541-990-0363
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. BENJAMIN JAMES
Credential	:	DDS
Telephone Number	:	541-666-6091

Provider Enumeration Date	:	08/09/2023
Last Update Date	:	05/30/2024

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