MEDICARE: CORNERSTONE DENTISTRY, 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	1223G0001X	General Practice Dentistry	D7796	OR

General Provider Information

NPI Number	:	1750838694
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORNERSTONE DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	10100 N MCALISTER RD
Second Line	:
City	:	ISLAND CITY
State	:	OR
Zip	:	97850-8701
Country	:	US
Telephone Number	:	541-963-6445
Fax Number	:	541-963-9012

Provider Business Practice Location Address
First Line	:	10100 N MCALISTER RD
Second Line	:
City	:	ISLAND CITY
State	:	OR
Zip	:	97850-8701
Country	:	US
Telephone Number	:	541-963-6445
Fax Number	:	541-963-9012

Authorized Official
Title or Position	:	OWNER/SOLE PROPRIETOR
Name	:	DR. BRIAN L KRUSE
Credential	:	DMD
Telephone Number	:	541-963-6445

Provider Enumeration Date	:	09/08/2016
Last Update Date	:	09/08/2016

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