MEDICARE: RICHARD D PUTNAM 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	1223G0001X	General Practice Dentistry	4861	OR

General Provider Information

NPI Number	:	1538227582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD D PUTNAM DMD

Provider Business Mailing Address
First Line	:	5892 MAIN ST STE 4
Second Line	:
City	:	SPRINGFIELD
State	:	OR
Zip	:	97478-5496
Country	:	US
Telephone Number	:	541-726-8816
Fax Number	:	541-741-8176

Provider Business Practice Location Address
First Line	:	5892 MAIN ST STE 4
Second Line	:
City	:	SPRINGFIELD
State	:	OR
Zip	:	97478-5496
Country	:	US
Telephone Number	:	541-726-8816
Fax Number	:	541-741-8176

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

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	07/08/2007

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