MEDICARE: ELEVEN ELEVEN 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	261QD0000X	Dental Clinic/Center	602789281	WA

General Provider Information

NPI Number	:	1073763041
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELEVEN ELEVEN DENTAL

Provider Business Mailing Address
First Line	:	1111 COLUMBIA ST
Second Line	:
City	:	PORT ANGELES
State	:	WA
Zip	:	98362-4207
Country	:	US
Telephone Number	:	360-457-3183
Fax Number	:

Provider Business Practice Location Address
First Line	:	1111 COLUMBIA ST
Second Line	:
City	:	PORT ANGELES
State	:	WA
Zip	:	98362-4207
Country	:	US
Telephone Number	:	360-457-3183
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. GREGORY L BIRCH
Credential	:	DDS
Telephone Number	:	360-457-3183

Provider Enumeration Date	:	09/25/2008
Last Update Date	:	09/25/2008

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