MEDICARE: RANDALL N FREED D.M.D., F.A.G.D.

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	5171	OR

General Provider Information

NPI Number	:	1184636110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDALL N FREED D.M.D., F.A.G.D.

Provider Business Mailing Address
First Line	:	12887 NW CORNELL RD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97229-5813
Country	:	US
Telephone Number	:	503-646-9687
Fax Number	:	503-619-0066

Provider Business Practice Location Address
First Line	:	12887 NW CORNELL RD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97229-5813
Country	:	US
Telephone Number	:	503-646-9687
Fax Number	:	503-619-0066

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

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	07/29/2010

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