MEDICARE: GEHRED FAMILY DENTAL

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	D9242	OR

General Provider Information

NPI Number	:	1043528169
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEHRED FAMILY DENTAL

Provider Business Mailing Address
First Line	:	4839 NE 42ND AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97218-1609
Country	:	US
Telephone Number	:	503-284-6469
Fax Number	:	503-288-0490

Provider Business Practice Location Address
First Line	:	4839 NE 42ND AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97218-1609
Country	:	US
Telephone Number	:	503-284-6469
Fax Number	:	503-288-0490

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CORNELIUS GEHRED
Credential	:	DDS
Telephone Number	:	503-284-6469

Provider Enumeration Date	:	09/23/2010
Last Update Date	:	09/23/2010

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