=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053614396
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES L BRANEN DMD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2010
-----------------------------------------------------
Last Update Date | 12/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4433 NE TILLAMOOK ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97213-1317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-288-6963
-----------------------------------------------------
Fax | 503-288-4939
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4433 NE TILLAMOOK ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97213-1317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-288-6963
-----------------------------------------------------
Fax | 503-288-4939
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. CHARLES LEE BRANEN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 503-288-6963
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | D7206
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------