MEDICARE: GARY T. PEDERSON

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	D4658	OR

General Provider Information

NPI Number	:	1154517415
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GARY T. PEDERSON

Provider Business Mailing Address
First Line	:	1565 LIBERTY ST SE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-4345
Country	:	US
Telephone Number	:	503-581-0223
Fax Number	:	503-581-6794

Provider Business Practice Location Address
First Line	:	1565 LIBERTY ST SE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-4345
Country	:	US
Telephone Number	:	503-581-0223
Fax Number	:	503-581-6794

Authorized Official
Title or Position	:	ORAL SURGEON
Name	:	DR. GARY T PEDERSON
Credential	:	DDS
Telephone Number	:	503-581-0223

Provider Enumeration Date	:	09/20/2007
Last Update Date	:	09/20/2007

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