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General NPI Number Information
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NPI Number | 1336216373
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Entity Type | Organization
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Legal Business Name | CENTRAL OREGON PERIO
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Dates
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Enumeration Date | 11/28/2006
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Last Update Date | 07/09/2010
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Provider Practice Location Address
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Address Line | 1569 SW NANCY WAY STE 3
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City | BEND
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State | OR
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Zip | 97702
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Country | US
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Telephone | 541-317-0255
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Fax | 541-317-0355
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Provider Business Mailing Address
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Address Line | 1569 SW NANCY WAY
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City | BEND
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State | OR
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Zip | 97702-3234
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Country | US
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Telephone | 541-317-0255
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Fax | 541-317-0355
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Authorized Official
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Title or Position | PRESIDENT
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Name | NICHOLAS W MISISCHIA
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Credential | DMD
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Telephone | 541-317-0255
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | D7709
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License Number State | OR
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