MEDICARE: DR. BRADLEY R HAGEDORN DMD

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	122300000X	Dentist	D9613	OR

General Provider Information

NPI Number	:	1265710420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRADLEY R HAGEDORN DMD

Provider Business Mailing Address
First Line	:	973 NW SALTZMAN RD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97229-5647
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	973 NW SALTZMAN RD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97229-5647
Country	:	US
Telephone Number	:	503-644-7202
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2011
Last Update Date	:	07/21/2011

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