MEDICARE: RICHARD D. SELLEN, DDS, INC.

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		CA

General Provider Information

NPI Number	:	1083149025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RICHARD D. SELLEN, DDS, INC.

Provider Business Mailing Address
First Line	:	1600 WILLOW ST
Second Line	:	SUITE 150
City	:	SAN JOSE
State	:	CA
Zip	:	95125-5115
Country	:	US
Telephone Number	:	408-264-3133
Fax Number	:	408-264-2312

Provider Business Practice Location Address
First Line	:	1600 WILLOW ST
Second Line	:	SUITE 150
City	:	SAN JOSE
State	:	CA
Zip	:	95125-5115
Country	:	US
Telephone Number	:	408-264-3133
Fax Number	:	408-264-2312

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RICHARD SELLEN
Credential	:	DDS
Telephone Number	:	480-544-6744

Provider Enumeration Date	:	04/27/2017
Last Update Date	:	04/27/2017

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