MEDICARE: GERIATRIC DENTAL GROUP

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	122300000X	Dentist	D8295	OR

General Provider Information

NPI Number	:	1760441216
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GERIATRIC DENTAL GROUP

Provider Business Mailing Address
First Line	:	19348 WINDMILL DR
Second Line	:
City	:	OREGON CITY
State	:	OR
Zip	:	92045
Country	:	US
Telephone Number	:	507-650-5296
Fax Number	:

Provider Business Practice Location Address
First Line	:	6319 SE POWELL BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97042
Country	:	US
Telephone Number	:	503-772-3677
Fax Number	:

Authorized Official
Title or Position	:	EXEC DIR
Name	:	MRS. PAMELA A LINDER
Credential	:	EXEC DIR
Telephone Number	:	503-772-3677

Provider Enumeration Date	:	03/22/2006
Last Update Date	:	08/22/2020

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