MEDICARE: DR. THOMAS CHANEZ D.D.S.

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	34312	CA

General Provider Information

NPI Number	:	1184743478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS CHANEZ D.D.S.

Provider Business Mailing Address
First Line	:	97651 MARINA HEIGHTS LOOP
Second Line	:
City	:	BROOKINGS
State	:	OR
Zip	:	97415-8203
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5905 LAKE EARL DRIVE
Second Line	:
City	:	CRESCENT CITY
State	:	CA
Zip	:	95531-7000
Country	:	US
Telephone Number	:	707-465-1000
Fax Number	:	707-465-9088

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

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	07/08/2007

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