MEDICARE: HOLLYWOOD CHILDREN'S DENTISTRY

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	1223P0221X	Pediatric Dentistry	D7649	OR

General Provider Information

NPI Number	:	1538438296
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLLYWOOD CHILDREN'S DENTISTRY

Provider Business Mailing Address
First Line	:	3839 NE TILLAMOOK ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-5338
Country	:	US
Telephone Number	:	503-288-5891
Fax Number	:	503-288-1525

Provider Business Practice Location Address
First Line	:	3839 NE TILLAMOOK ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-5338
Country	:	US
Telephone Number	:	503-288-5891
Fax Number	:	503-288-1525

Authorized Official
Title or Position	:	OWNER/PARTNER
Name	:	DR. KRISTA V BADGER
Credential	:	DDS
Telephone Number	:	503-288-5891

Provider Enumeration Date	:	12/23/2011
Last Update Date	:	12/23/2011

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