MEDICARE: SLEEP DENTISTRY OF PORTLAND LLC

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	124Q00000X	Dental Hygienist	H1529	OR
2	1223G0001X	General Practice Dentistry	D8126	OR
3	1223G0001X	General Practice Dentistry	D8648	OR
4	1223G0001X	General Practice Dentistry	D4528	OR

General Provider Information

NPI Number	:	1265557789
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SLEEP DENTISTRY OF PORTLAND LLC

Provider Business Mailing Address
First Line	:	19265 SE STARK ST
Second Line	:	SUITE A
City	:	PORTLAND
State	:	OR
Zip	:	97233-5758
Country	:	US
Telephone Number	:	503-666-9519
Fax Number	:

Provider Business Practice Location Address
First Line	:	19265 SE STARK ST
Second Line	:	SUITE A
City	:	PORTLAND
State	:	OR
Zip	:	97233-5758
Country	:	US
Telephone Number	:	503-666-9519
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. BRANDON C. KASCH
Credential	:
Telephone Number	:	503-666-9519

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	09/12/2008

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