MEDICARE: DR. MARY KATHLEEN HARRELL DMD

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	122300000X	Dentist	D7115	OR
2	1223G0001X	General Practice Dentistry	D7115	OR
3	1223G0001X	General Practice Dentistry	9161076	ID

General Provider Information

NPI Number	:	1083640007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY KATHLEEN HARRELL DMD

Provider Business Mailing Address
First Line	:	2222 SW QUINNEY DR.
Second Line	:
City	:	PENDLETON
State	:	OR
Zip	:	97801
Country	:	US
Telephone Number	:	541-240-4497
Fax Number	:	541-504-3907

Provider Business Practice Location Address
First Line	:	1519 NE F ST
Second Line	:
City	:	GRANTS PASS
State	:	OR
Zip	:	97526-4234
Country	:	US
Telephone Number	:	542-240-5678
Fax Number	:

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

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	07/14/2025

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