MEDICARE: ESTATE OF KEVIN L. CHANCELLOR

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	D5874	OR

General Provider Information

NPI Number	:	1518106228
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ESTATE OF KEVIN L. CHANCELLOR

Provider Business Mailing Address
First Line	:	3173 NE WEST DEVILS LAKE RD
Second Line	:
City	:	LINCOLN CITY
State	:	OR
Zip	:	97367
Country	:	US
Telephone Number	:	541-994-8135
Fax Number	:	541-994-8136

Provider Business Practice Location Address
First Line	:	3173 NE WEST DEVILS LAKE RD
Second Line	:
City	:	LINCOLN CITY
State	:	OR
Zip	:	97367
Country	:	US
Telephone Number	:	541-994-8135
Fax Number	:	541-994-8136

Authorized Official
Title or Position	:	OFFICE ADMINISTRATOR
Name	:	MRS. DANIELLE M CHANCELLOR
Credential	:	CDA-EFDA
Telephone Number	:	541-994-8135

Provider Enumeration Date	:	02/19/2009
Last Update Date	:	02/19/2009

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