MEDICARE: NICK R. MELLUM DMD PC

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	1223G0001X	General Practice Dentistry	D8836	OR

General Provider Information

NPI Number	:	1013281484
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NICK R. MELLUM DMD PC

Provider Business Mailing Address
First Line	:	8910 N KELLOGG ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97203-3002
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8910 N KELLOGG ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97203-3002
Country	:	US
Telephone Number	:	503-286-4492
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. NICK MELLUM
Credential	:	DMD
Telephone Number	:	503-286-4492

Provider Enumeration Date	:	03/02/2012
Last Update Date	:	03/02/2012

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