MEDICARE: DR. RAYMOND MCREADY TRAVIS VANDERWERF DDS, CAGS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	2117	AZ

General Provider Information

NPI Number	:	1013126101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RAYMOND MCREADY TRAVIS VANDERWERF DDS, CAGS

Provider Business Mailing Address
First Line	:	1630 S STAPLEY DR
Second Line	:	#208
City	:	MESA
State	:	AZ
Zip	:	85204-6657
Country	:	US
Telephone Number	:	480-775-2656
Fax Number	:

Provider Business Practice Location Address
First Line	:	1630 S STAPLEY DR
Second Line	:	#208
City	:	MESA
State	:	AZ
Zip	:	85204-6657
Country	:	US
Telephone Number	:	480-775-2656
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	07/08/2007

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