MEDICARE: DENTAL PROFESSIONALS OF OREGON, P.C.

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1194499715
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL PROFESSIONALS OF OREGON, P.C.

Provider Business Mailing Address
First Line	:	1296 COMMERCIAL ST SE STE 101
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-4200
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1296 COMMERCIAL ST SE STE 101
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-4200
Country	:	US
Telephone Number	:	503-585-4282
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	TABATHA LEMKE
Credential	:
Telephone Number	:	217-540-6078

Provider Enumeration Date	:	08/06/2021
Last Update Date	:	08/06/2021

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