MEDICARE: GENTLE DENTAL OREGON LLC

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

General Provider Information

NPI Number	:	1245354075
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENTLE DENTAL OREGON LLC

Provider Business Mailing Address
First Line	:	1419 W OREGON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-4926
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1419 W OREGON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-4926
Country	:	US
Telephone Number	:	215-469-0220
Fax Number	:	215-551-0488

Authorized Official
Title or Position	:	INSURANCE DIRECTOR
Name	:	MIKE COLE
Credential	:
Telephone Number	:	727-726-1611

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	06/27/2011

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