MEDICARE: DR. CYNTHIA MARION PETICOLAS 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	1223G0001X	General Practice Dentistry	5986	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134180714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CYNTHIA MARION PETICOLAS DMD

Provider Business Mailing Address
First Line	:	PO BOX 260
Second Line	:
City	:	MILL CITY
State	:	OR
Zip	:	97360
Country	:	US
Telephone Number	:	503-897-2353
Fax Number	:	503-897-2354

Provider Business Practice Location Address
First Line	:	548 S 1ST AVE
Second Line	:
City	:	MILL CITY
State	:	OR
Zip	:	97360
Country	:	US
Telephone Number	:	503-897-2353
Fax Number	:	503-897-2354

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

Provider Enumeration Date	:	03/31/2006
Last Update Date	:	05/26/2015

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