MEDICARE: BROOKSIDE DENTAL-SELLWOOD, 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1578151791
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOKSIDE DENTAL-SELLWOOD, LLC

Provider Business Mailing Address
First Line	:	22400 SALAMO RD
Second Line	:
City	:	WEST LINN
State	:	OR
Zip	:	97068-8269
Country	:	US
Telephone Number	:	503-723-8722
Fax Number	:

Provider Business Practice Location Address
First Line	:	5805 SE MILWAUKIE AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97202-5255
Country	:	US
Telephone Number	:	503-233-5825
Fax Number	:

Authorized Official
Title or Position	:	REGIONAL MANAGER
Name	:	DEBBIE LOPEZ
Credential	:
Telephone Number	:	503-914-8221

Provider Enumeration Date	:	01/04/2021
Last Update Date	:	01/04/2021

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