MEDICARE: GARY THEODORE PEDERSON D.D.S.

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	D4658	OR

General Provider Information

NPI Number	:	1447258223
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY THEODORE PEDERSON D.D.S.

Provider Business Mailing Address
First Line	:	1565 LIBERTY ST SE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-4345
Country	:	US
Telephone Number	:	503-581-0223
Fax Number	:	503-581-6794

Provider Business Practice Location Address
First Line	:	1565 LIBERTY ST SE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-4345
Country	:	US
Telephone Number	:	503-581-0223
Fax Number	:	503-581-6794

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

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	07/17/2007

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