MEDICARE: BEVERLY VERNWALD LD

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	122400000X	Denturist	DTDO694389	OR

General Provider Information

NPI Number	:	1801017033
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEVERLY VERNWALD LD

Provider Business Mailing Address
First Line	:	7121 N SWIFT ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97203-1368
Country	:	US
Telephone Number	:	503-289-5862
Fax Number	:

Provider Business Practice Location Address
First Line	:	2905 SE OAK GROVE BLVD
Second Line	:	SUITE 3
City	:	MILWAUKIE
State	:	OR
Zip	:	97267-1300
Country	:	US
Telephone Number	:	503-654-4583
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	07/08/2007

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