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NPI Code Detail

MEDICARE: DR. TIMOTHY JOHN EDVALSON D.M.D.

MEDICARE: DR. TIMOTHY JOHN EDVALSON D.M.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
11223G0001XGeneral Practice DentistryD5825OR

General Provider Information

NPI Number : 1205821154
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. TIMOTHY JOHN EDVALSON D.M.D.
Provider Business Mailing Address
First Line : 3900 DOUGLAS WAY
Second Line :
City : LAKE OSWEGO
State : OR
Zip : 97035-3446
Country : US
Telephone Number : 503-636-8446
Fax Number : 503-636-4446
Provider Business Practice Location Address
First Line : 3900 DOUGLAS WAY
Second Line :
City : LAKE OSWEGO
State : OR
Zip : 97035-3446
Country : US
Telephone Number : 503-636-8446
Fax Number : 503-636-4446
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/16/2005
Last Update Date : 07/08/2007

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