MEDICARE: CRISDENTAL SALEM L.L.C.

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

General Provider Information

NPI Number	:	1760741078
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRISDENTAL SALEM L.L.C.

Provider Business Mailing Address
First Line	:	1333 W HARVARD AVE
Second Line	:
City	:	ROSEBURG
State	:	OR
Zip	:	97471-2838
Country	:	US
Telephone Number	:	541-672-2747
Fax Number	:

Provider Business Practice Location Address
First Line	:	1355 EDGEWATER ST NW
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97304-4077
Country	:	US
Telephone Number	:	503-588-6960
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL J BRATLAND
Credential	:	D.M.D.
Telephone Number	:	541-672-2747

Provider Enumeration Date	:	05/07/2012
Last Update Date	:	05/07/2012

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Directions to “CRISDENTAL SALEM L.L.C. ” Practice Location

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