Healthcare Provider Details

I. General information

NPI: 1831177385
Provider Name (Legal Business Name): DAVID L DEDRICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2042 NE WILLIAMSON CT ST. CHARLES SLEEP CENTER - BEND
BEND OR
97701-3760
US

IV. Provider business mailing address

PO BOX 5579
BEND OR
97708-5579
US

V. Phone/Fax

Practice location:
  • Phone: 541-706-6905
  • Fax: 541-371-4580
Mailing address:
  • Phone: 541-706-6905
  • Fax: 541-371-4580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberMD19899
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD19899
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: