Healthcare Provider Details

I. General information

NPI: 1073772299
Provider Name (Legal Business Name): BRIAN S. BISHOP DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 06/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 TOWN CENTRE DR
MEDFORD OR
97504-6186
US

IV. Provider business mailing address

925 TOWN CENTRE DR
MEDFORD OR
97504-6186
US

V. Phone/Fax

Practice location:
  • Phone: 541-772-0102
  • Fax:
Mailing address:
  • Phone: 541-772-0102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD9489
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD7527
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: