MEDICARE: CASCADE ENDODONTIC GROUP 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	1223E0200X	Endodontics	D8490	OR
2	1223E0200X	Endodontics	D8211	OR

General Provider Information

NPI Number	:	1265698351
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CASCADE ENDODONTIC GROUP LLC

Provider Business Mailing Address
First Line	:	1590 NE WILLIAMSON BLVD
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97701-6071
Country	:	US
Telephone Number	:	541-388-1500
Fax Number	:	541-388-6995

Provider Business Practice Location Address
First Line	:	1590 NE WILLIAMSON BLVD
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97701-6071
Country	:	US
Telephone Number	:	541-388-1500
Fax Number	:	541-388-6995

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	ELIZABETH EDMUNDS
Credential	:
Telephone Number	:	541-388-1500

Provider Enumeration Date	:	07/29/2008
Last Update Date	:	07/29/2008

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