MEDICARE: BROCK D. HERRIGES, DMD, LLC

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	1223P0300X	Periodontics	D8371	OR

General Provider Information

NPI Number	:	1568850279
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROCK D. HERRIGES, DMD, LLC

Provider Business Mailing Address
First Line	:	1130 SE 122ND AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97233-1112
Country	:	US
Telephone Number	:	503-252-5515
Fax Number	:	503-255-1625

Provider Business Practice Location Address
First Line	:	1130 SE 122ND AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97233-1112
Country	:	US
Telephone Number	:	971-221-6744
Fax Number	:	503-255-1625

Authorized Official
Title or Position	:	PERIODONTIST
Name	:	DR. BROCK D HERRIGES
Credential	:	DMD
Telephone Number	:	503-252-5515

Provider Enumeration Date	:	01/05/2015
Last Update Date	:	01/05/2015

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