MEDICARE: THOMAS A BASE 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	D6511	OR

General Provider Information

NPI Number	:	1235404492
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THOMAS A BASE DMD

Provider Business Mailing Address
First Line	:	10420 NE WASCO ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97220-3928
Country	:	US
Telephone Number	:	503-256-2090
Fax Number	:

Provider Business Practice Location Address
First Line	:	10420 NE WASCO ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97220-3928
Country	:	US
Telephone Number	:	503-256-2090
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. THOMAS A BASE
Credential	:	D.M.D.
Telephone Number	:	503-256-2090

Provider Enumeration Date	:	03/20/2012
Last Update Date	:	03/20/2012

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