MEDICARE: DR. DANIEL E BLICKENSTAFF DDS

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	D6921	OR

General Provider Information

NPI Number	:	1073572459
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANIEL E BLICKENSTAFF DDS

Provider Business Mailing Address
First Line	:	975 NW SALTZMAN RD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97229-5647
Country	:	US
Telephone Number	:	503-646-1463
Fax Number	:	503-646-0753

Provider Business Practice Location Address
First Line	:	975 NW SALTZMAN RD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97229-5647
Country	:	US
Telephone Number	:	503-646-1463
Fax Number	:	503-646-0753

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

Provider Enumeration Date	:	03/22/2006
Last Update Date	:	07/08/2007

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