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General NPI Number Information
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NPI Number | 1407100233
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Entity Type | Individual
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Provider Name | CODY MERRIL BYWATERS LICENSED DENTURIST
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Gender | Male
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Dates
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Enumeration Date | 10/31/2012
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Last Update Date | 10/31/2012
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Provider Practice Location Address
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Address Line | 3900 DOUGLAS WAY
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City | LAKE OSWEGO
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State | OR
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Zip | 97035-3446
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Country | US
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Telephone | 503-635-8060
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Fax | 503-305-8679
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Provider Business Mailing Address
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Address Line | 3900 DOUGLAS WAY
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City | LAKE OSWEGO
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State | OR
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Zip | 97035-3446
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Country | US
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Telephone | 503-635-8060
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Fax | 503-305-8679
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122400000X
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Taxonomy Name | Denturist
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License Number | DTDO10126042
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License Number State | OR
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